Abdominal Compartment Syndrome and Intra-abdominal Ischemia in Patients with Severe Acute Pancreatitis

World J Surg (2016) 40:1454–1461 DOI 10.1007/s00268-015-3388-7 ORIGINAL SCIENTIFIC REPORT Abdominal Compartment Syndrome and Intra-abdominal Ischemia in Patients with Severe Acute Pancreatitis M. Smit1 • K. T. Buddingh1,2 • B. Bosma1 • V. B. Nieuwenhuijs2 • H. S. Hofker2 • J. G. Zijlstra1 Published online: 1 February 2016  The Author(s) 2016. This article is published with open access at Springerlink.com Abstract Introduction Severe acute pancreatitis may be complicated by intra-abdominal hypertension (IAH), abdominal compartment syndrome (ACS), and intestinal ischemia. The aim of this retrospective study is to describe the incidence, treatment, and outcome of patients with severe acute pancreatitis and ACS, in particular the occurrence of intestinal ischemia. Methods The medical records of all patients admitted with severe acute pancreatitis admitted to the ICU of a tertiary referral center were reviewed. The criteria proposed by the World Society of the Abdominal Compartment Syndrome (WSACS) were used to determine whether patients had IAH or ACS. Results Fifty-nine patients with severe acute pancreatitis were identified. Intra-abdominal pressure (IAP) measurements were performed in 29 patients (49.2 %). IAH was present in all patients (29/29). ACS developed in 13/29 (44.8 %) patients. Ten patients with ACS underwent decompressive laparotomy. A large proportion of patients with ACS had intra-abdominal ischemia upon laparotomy: 8/13 (61.5 %). Mortality was high in both the ACS group and the IAH group. Conclusion This study confirms that ACS is common in severe acute pancreatitis. Intra-abdominal ischemia occurs in a large proportion of patients with ACS. Swift surgical intervention may be indicated when conservative measures fail in patients with ACS. National and international guidelines need to be updated so that routine IAP measurements become standard of care for patients with severe acute pancreatitis in the ICU. Abbreviations ACS Abdominal compartment syndrome ERCP Endoscopic retrograde cholangiopancreatography IAP Intra-abdominal pressure IAH Intra-abdominal hypertension & M. Smit 1 Department of Critical Care (BA 49), University Medical Center Groningen, University of Groningen, PO Box 30001, 9700 RB Groningen, The Netherlands 2 Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands 123 ICU IQR MOF SAP SD VARD WSACS Intensive care unit Inter-quartile range Multiple organ failure Severe acute pancreatitis Standard deviation Video-assisted retroperitoneal debridement World Society of the Abdominal Compartment Syndrome Introduction Acute pancreatitis is a well-established risk factor for intraabdominal hypertension (IAH) and abdominal compartment syndrome (ACS) [1]. The incidence of IAH in World J Surg (2016) 40:1454–1461 patients with severe acute pancreatitis is approximately 60 % [2, 3], while ACS may occur in approximately 30 % [2]. The mortality of patients with severe acute pancreatitis who develop ACS is high at 50–75 % [2–4]. Respiratory, renal, and cardiovascular organ failures have been reported in patients with ACS. Furthermore, ACS may cause mesenteric hypoperfusion and subsequent ischemia of intra-abdominal organs [5]. Mesenteric ischemia and necrosis may also develop in severe acute pancreatitis [6]. Ischemia–reperfusion injury due in IAH and ACS has mainly been studied in animal models [7–9]. In a retrospective series in 26 children with ACS, 19 % required bowel resection due to ischemic necrosis [10]. Furthermore, raised IAP may be an important mechanism behind colonic hypoperfusion after ruptured aortic aneurysm repair [11]. However, there has not yet been a series detailing the occurrence of mesenteric ischemia in patients with severe acute pancreatitis and ACS. The aim of this study is to describe the incidence, treatment, and outcome of patients with severe acute pancreatitis and ACS in the intensive care unit (ICU), in particular the occurrence of intestinal ischemia. 1455 Patients This study was conducted at a tertiary referral center for patients with severe acute pancreatitis. Patients were included who met the following criteria: (1) who were admitted to the ICU between January 2005 and May 2011 and (2) who met the revised Atlanta criteria for severe acute pancreatitis. Patients were excluded if they met any of the following criteria: (1) age under 18 years; (2) history of chronic pancreatitis; (3) admission after resuscitation for cardiac arrest; and (4) pancreatitis was diagnosed postmortem. Furthermore, one patient was excluded because the medical records were incomplete. Medical records of all patients were examined; this included examination of the daily nursing charts where intra-abdominal pressure (IAP) measurements are noted, the admission notes and ICU discharge notes, the discharge notes of the general ward, all surgery reports, and all microbiologic culture reports. Transvesical IAP measurement was performed according to a standard protocol based on the WSACS consensus definitions [1]. Materials and methods Statistical analysis Definitions Severe acute pancreatitis (SAP) Acute pancreatitis with persistent organ failure ([48 h) as defined by the revised Atlanta criteria [12]. Multiple organ failure (MOF) Descriptive statistics were used. Dichotomous data were presented by proportions and continuous data by means (with standard deviations) or medians (with rages) according to normality. Pearson’s v2 test, paired and independent Student T tests, and Mann–Whitney tests were used as appropriate. Due to small numbers of events, multivariate analysis was deemed inappropriate. The failure of [1 organ system (respiratory, renal, or cardiovascular) [12]. Results Intra-abdominal hypertension (IAH) Patient characteristics A sustained or repeated pathological elevation in IAP of 12 mmHg or higher [1] categorized into grade I (IAP 12–15 mmHg), grade II (16–20 mmHg), grade III (21–25 mmHg), and grade IV ([25 mmHg). Abdominal compartment Syndrome (ACS) A sustained IAP [20 mmHg that is associated with new organ dysfunction/failure, as defined by the World Society of the Abdominal Compartment Syndrome (WSACS) [1]. Fifty-nine patients were identified that met the inclusion criteria. Most patients were males, around 60 years old and referred from a regional hospital. The mean interval between admission to a (regional) hospital and the tertiary ICU was 13.4 days (SD 20.7, range 0–123). The most common etiology was gallstones (40.7 %), followed by alcoholic pancreatitis (22.0 %). Most patients were critically ill; 84.7 % had MOF and 62.7 % had infected pancreatic necrosis at some point during their illness. 123 1456 World J Surg (2016) 40:1454–1461 Intra-abdominal pressure Treatment of ACS Patient characteristics and IAP measurements are summarized in Table 1. IAP measurement was performed in 29 out of 59 patients (49.2 %). Age and Apache II scores did not diffe (...truncated)