Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective

Hindawi Publishing Corporation Gastroenterology Research and Practice Volume 2016, Article ID 5251806, 6 pages http://dx.doi.org/10.1155/2016/5251806 Review Article Interventional Treatment of Abdominal Compartment Syndrome during Severe Acute Pancreatitis: Current Status and Historical Perspective Dejan V. Radenkovic,1 Colin D. Johnson,2 Natasa Milic,3 Pavle Gregoric,4 Nenad Ivancevic,4 Mihailo Bezmarevic,5 Dragoljub Bilanovic,6 Vladimir Cijan,7 Andrija Antic,1 and Djordje Bajec1 1 Clinic for Digestive Surgery, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia Department of Surgery, University Hospital Southampton, Southampton, UK 3 Institute for Biostatistics and Informatics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia 4 Clinic for Emergency Surgery, Emergency Center, Clinical Center of Serbia, Faculty of Medicine, University of Belgrade, Belgrade, Serbia 5 Clinic for Surgery, Military Medical Academy, Belgrade, Serbia 6 Clinic for Surgery, Clinical Center “Bezanijska Kosa”, Faculty of Medicine, University of Belgrade, Belgrade, Serbia 7 Clinic for Surgery, Clinical Center “Zvezdara”, Belgrade, Serbia 2 Correspondence should be addressed to Dejan V. Radenkovic; Received 13 July 2015; Accepted 26 November 2015 Academic Editor: Giuseppe Malleo Copyright © 2016 Dejan V. Radenkovic et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a marker of severe disease. It occurs as combination of inflammation of retroperitoneum, visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and aggressive fluid resuscitation. The frequency of ACS in SAP may be rising due to more aggressive fluid resuscitation, a trend towards conservative treatment, and attempts to use a minimally invasive approach. There remains uncertainty about the most appropriate surgical technique for the treatment of ACS in SAP. Some unresolved questions remain including medical treatment, indications, timing, and interventional techniques. This review will focus on interventional treatment of this serious condition. First line therapy is conservative treatment aiming to decrease IAP and to restore organ dysfunction. If nonoperative measures are not effective, early abdominal decompression is mandatory. Midline laparostomy seems to be method of choice. Since it carries significant morbidity we need randomized studies to establish firm advantages over other described techniques. After ACS resolves efforts should be made to achieve early primary fascia closure. Additional data are necessary to resolve uncertainties regarding ideal timing and indication for operative treatment. 1. Introduction The morbidity and mortality of patients with severe acute pancreatitis (SAP) remain high despite significant improvement in treatment due to the better understanding of the pathophysiology of disease, early aggressive fluid resuscitation, timely surgical intervention, permanent monitoring, and organ supporting intensive care. It is widely accepted that major predictors of unfavorable outcome are development of persistent organ failure and presence of bacterial infection of necrosis [1]. Abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) is a sign of severe disease with high risk of adverse outcomes [2–5]. Abdominal compartment syndrome is defined as a state of serious organ dysfunction resulting from sustained increase in 2 intra-abdominal pressure [6]. Very recently published systematic review on this topic showed that the mortality rate in patients who developed ACS during SAP was 49%, while it was 11% in patients without this complication [7]. The number of patients with ACS may have increased as a consequence of a move towards later intervention and minimally invasive rather than open surgery. Several studies demonstrated that development of organ failure in SAP is in correlation with presence of intra-abdominal hypertension (IAH) [3, 4, 8, 9]. Elevated intra-abdominal pressure (IAP) is well known predictor of mortality and serial measurements of IAP are recommended for all patients with severe acute pancreatitis in the intensive care units [6]. Currently there is no agreed surgical or other interventional treatment for ACS during the course of SAP. The World Society of Abdominal Compartment Syndrome (WSACS) has published definitions of IAH and ACS and recommendations for treatment [6], but it is not known if these can be applied to patients with SAP. During recent years, several studies on ACS in patients with SAP have been published, but data of this problem still remains scarce [3, 10–13]. Some unresolved questions including medical treatment, indications, timing, and interventional techniques remain, and this review will focus on interventional treatment of this serious condition. 2. Pathophysiology There are several reasons which may contribute to development of IAP during SAP. Inflammation of the pancreas is a crucial step, which starts a cascade of events including visceral edema, ascites, acute peripancreatic fluid collections, paralytic ileus, and duodenal obstruction causing gastric dilatations. Aggressive fluid resuscitation, a very important part of initial conservative treatment, is an additional factor leading to rapid fluid accumulation in the abdominal cavity which plays a role in elevation of IAP. Severe intra-abdominal inflammation together with capillary leakage further contributes to development of large quantity of ascites. The abdominal wall may also be edematous with decreased compliance, which in synergy with enlarged intra-abdominal volume leads to an increase of IAP. The presence of large peripancreatic fluid collections and paralytic ileus may also play a significant role in development of IAH. Intra-abdominal hypertension leads to reduction of chest wall compliance and hypoperfusion of the gastrointestinal tract [14] which contribute significantly to the pathogenesis of organ dysfunction [15, 16]. Elevated IAP may reduce perfusion of abdominal organs, allowing hypoxic injury of the surrounding tissues which could exacerbate systemic inflammatory response. High IAP in patients with severe acute pancreatitis correlates with the degree of organ dysfunction and intensive care stay [9]. An IAP above 20 mmHg is associated with oliguria and significant reduction in cardiac output [17]. IAH appears to exacerbate organ failure, as it is associated with significantly higher APACHE II scores and MODS scores in patients with SAP [4, 5]. De Waele et al. [8] reported a higher incidence of respiratory, circulatory, and renal failure among the patients Gastroenterology Research and Practice with IAH. Elevation of the diaphragm due (...truncated)