Surgical decompression for the management of abdominal compartment syndrome with severe acute pancreatitis: A narrative review

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome(ACS)play a pivotal role in the pathophysiology of severe acute pancreatitis(SAP)and contribute to new-onset and persistent organ failure.The optimal management of ACS involves a multi-disciplinary approach,from its early recognition to measures aiming at an urgent reduction of intra-abdominal pressure(IAP).A targeted literature search from January 1,2000,to November 30,2022,revealed 20 studies and data was analyzed on the type and country of the study,patient demographics,IAP,type and timing of surgical procedure performed,post-operative wound management,and outcomes of patients with ACS.There was no randomized controlled trial published on the topic.Decom-pressive laparotomy is effective in rapidly reducing IAP(standardized mean difference=2.68,95%confidence interval:1.19-1.47,P<0.001;4 studies).The morbidity and complications of an open abdomen after decompressive laparotomy should be weighed against the inadequately treated but,potentially lethal ACS.Disease-specific patient selection and the role of less-invasive decompressive measures,like subcutaneous linea alba fasciotomy or component separation techniques,is lacking in the 2013 consensus management guidelines by the Abdominal Compartment Society on IAH and ACS.This narrative review focuses on the current evidence regarding surgical decompression techniques for managing ACS in patients with SAP.However,there is a lack of high-quality evidence on patient selection,timing,and modality of surgical decompression.Large prospective trials are needed to identify triggers and effective and safe surgical decompression methods in SAP patients with ACS.

Gouty tenosynovitis with compartment syndrome in the hand: A case report

BACKGROUND Gout is a common type of inflammatory arthritis caused by the deposition of monosodium urate crystals in the joints and surrounding tissues.It typically appears with abrupt and intense pain,redness,and swelling in the affected joint.It frequently targets the lower extremities,such as the big toe.However,rarely,gout can manifest in atypical locations,including the hands,leading to an uncommon presentation known as gouty tenosynovitis.However,it can result in significant morbidity owing to the potential for severe complications,such as myonecrosis and compartment syndrome.CASE SUMMARY An 82-year-old male patient with a history of hypertension,cerebral infarction,Parkinson's disease,and recurrent gout attacks sought medical attention because of progressive pain and swelling in the right hand.Imaging findings revealed forearm swelling,raising concerns of possible tenosynovitis,bursitis,septic arthritis,and compartment syndrome.A fasciotomy was performed to decompress the patient’s hands and forearms.The procedure revealed diffuse tenosynovitis,tophi with a pus-like discharge surrounding the carpal tunnel,and involvement of the flexor and extensor tendon sheaths.However,microbiological investigations,including Gram staining,acid-fast bacilli,tuberculosis,and nontuberculous mycobacteria,yielded negative results.The patient was ultimately diagnosed with a severe gouty attack with compartment syndrome and myonecrosis.Septic arthritis and infectious flexor tenosynovitis were ruled out.Serial debridement and inflammation control were initiated,followed by staged closure with a skin graft.CONCLUSION Septic-like complications can occur in the absence of infection in severe gout attacks with pus-like discharges due to compartment syndrome and myonecrosis.Cultures can be used to differentiate between gouty attacks,septic arthritis,and infectious tenosynovitis.Involvement of the flexor and extensor muscles,as in this case,is rare.This study contributes to the literature by reporting a rare case of successful fasciotomy and serial debridement in an elderly patient with multiple comorbidities.

Finger compartment syndrome due to a high-pressure washer injury:A case report

BACKGROUND Although the finger compartment syndrome is not common,it compresses the neurovascular bundles in a limited space and blocks blood flow to the fingers,causing necrosis of the fingertips.Finger fasciotomy through unilateral or bilateral midline release of the finger can achieve decompression of the finger compartment.Herein,we report a case of the compartment syndrome in a finger injury caused by a high-pressure water flow which is commonly used in car washing stations.CASE SUMMARY A 60-year-old man injured his right middle finger while using a high-pressure washer at a car washing station.The patient complained of severe pain in his middle finger and a 0.2 cm punctured open wound on the volar side of the distal phalangeal joint of the middle finger.The fingertip was pale,numb,and characterized by severe swelling and a limited range of motion.Finger radiography showed that there was no fracture in the finger.Digital decompression was performed through finger fasciotomy by bilateral midline incision.On the second day after surgery,the color of the fingertip returned to pink,swelling was resolved,and the range of motion returned to normal.The sensation of the fingertip was completely restored,and the capillary refill test and pinprick test were positive.CONCLUSION The fingertip compartment syndrome can be caused by a high-pressure water flow damage to the fingers when using high-pressure washers at a car washing station.To avoid finger necrosis,rapid diagnosis of the finger compartment syndrome and appropriate digital decompression are essential to better outcome.

Nursing outcomes of traditional Chinese medicine adjunctive therapy on osteofascial compartment syndrome:a review

The rate of disability due to acute osteofascial compartment syndrome(OCS)is high,and the therapeutic effect of decompressive fasciotomy is not ideal.This paper retrospectively reviews the modern treatment of OCS,including Western medicine and Traditional Chinese medicine(TCM),mainly in the context of the advantages of TCM in the treatment process of decompressive fasciotomy or conservative treatment to the patients who are suffering from OCS.It was found that TCM treatment reduced the levels of serum creatine kinase(CK),lactate dehydrogenase(LDH),and aspartate aminotransferase(AST);it is beneficial to the elimination of swelling and pain.TCM adjunctive therapy promotes patients’postoperative functional recovery and decreases the occurrence of fasciotomy in patients;TCM can relieve tissue hypoxia of compartments and prevent necrosis of muscle and nerve tissue.TCM treatment improves the quality of medical service and ensures the safety of OCS patients.This paper aims to summarize the function of TCM in the treatment of OCS,provide reference for the clinical treatment of OCS,and improve the nursing/medical outcomes of OCS.

Isolated lateral leg compartment syndrome:A case report

BACKGROUND Acute leg compartment syndrome is a well-known orthopedic emergency associated with potentially devastating consequences if not treated immediately.Multiple compartments are usually involved with a clear history of trauma and classic symptoms and signs.However,isolated lateral leg compartment syndrome is relatively rare and is often misdiagnosed due to the atypical presentation of no trauma and the lack of pathognomonic signs.CASE SUMMARY A 31-year-old male patient presented to our emergency room with excruciating left calf pain and inability to mobilize one-day after participating in a football match despite no clear history of preceding trauma.The patient went to another hospital before presenting to us where he was diagnosed to have a soft tissue injury and was discharged home on simple analgesics.On clinical examination,the left leg showed a tense lateral compartment with severe tenderness.The pain was aggravated by dorsiflexion and ankle inversion.Neurovascular examination of the limb was normal.We suspected a compartment syndrome but as the presentation was atypical and an magnetic resonance imaging(MRI)was readily available in our institution,we immediately performed an MRI and this confirmed a large hematoma in the lateral compartment with a possible partial proximal peroneus longus muscle tear.The patient was taken immediately for an emergency open fasciotomy.The patient is now 18 mo postoperatively having recovered completely and engages fully in sports with no restrictions.CONCLUSION Atypical presentation due to the lack of pathognomonic signs makes the diagnosis of isolated lateral leg compartment syndrome difficult.Pain on passive inversion and dorsiflexion and weak active eversion may be suggested as sensitive signs.

Endoscopic fasciotomy for chronic exertional compartment syndrome of the forearm:Systematic review of outcomes and complications

BACKGROUND Endoscopic fasciotomy of the forearm for chronic exertional compartment syndrome(CECS)has gained popularity recently.AIM To systematically review the literature of endoscopic fasciotomy for CECS of the forearm,aiming to assess the outcomes and complications of the different endoscopic fasciotomy techniques described in the literature.METHODS On January 18,2021,PubMed and EMBASE were searched by 3 reviewers independently,and all relevant studies published up to that date were considered based on predetermined inclusion/exclusion criteria.The subject headings“endoscopic fasciotomy”and“compartment syndrome”and their related key terms were used.The Preferred Reporting Item for Systematic Reviews and Meta-Analyses statement was used to screen the articles.RESULTS A total of seven studies including 183 patients(355 forearms)were included.The mean age of the patients was 31.2 years(range:15-42 years).The postoperative follow-up duration ranged from 6 wk to 4.9 years.All patients were able to return to sport activities between postoperative weeks 1 to 8.Recurrence of the compartment syndrome occurred in three patients,giving a rate of 1.6%per patient and 0.8%per forearm.The overall complication rate was 8.7%per patient,and 4.5%per forearm.The most common reported complication was hematoma(7 forearms;2.0%).CONCLUSION Endoscopic fasciotomy for CECS of the forearm has favorable short-and midterm outcomes with very low recurrence and complication rates.This,however,needs to be confirmed in larger,long-term follow-up,prospective,comparative studies between open,mini-open and endoscopic fasciotomy techniques.

Abdominal compartment syndrome:Often overlooked conditions in medical intensive care units

Intra-abdominal hypertension(IAH)and abdominal compartment syndrome are well recognized entities among surgical patients.Nevertheless,a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units(ICU)and has been widely recognized as an independent risk factor for mortality.It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality.Frequently it is underdiagnosed and undertreated in this patient population.Elevated intraabdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure.When intraabdominal hypertension is not promptly recognized and treated,it leads to abdominal compartment syndrome,multiorgan dysfunction syndrome and death.Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis,shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension.This article presents an overview of the epidemiology,definitions,risk factors,pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.

Abdominal compartment syndrome among surgical patients

Abdominal compartment syndrome(ACS)develops when organ failure arises secondary to an increase in intraabdominal pressure.The abdominal pressure is determined by multiple factors such as blood pressure,abdominal compliance,and other factors that exert a constant pressure within the abdominal cavity.Several conditions in the critically ill may increase abdominal pressure compromising organ perfusion that may lead to renal and respiratory dysfunction.Among surgical and trauma patients,aggressive fluid resuscitation is the most commonly reported risk factor to develop ACS.Other conditions that have also been identified as risk factors are ascites,hemoperitoneum,bowel distention,and large tumors.All patients with abdominal trauma possess a higher risk of developing intra-abdominal hypertension(IAH).Certain surgical interventions are reported to have a higher risk to develop IAH such as damage control surgery,abdominal aortic aneurysm repair,and liver transplantation among others.Close monitoring of organ function and intra-abdominal pressure(IAP)allows clinicians to diagnose ACS rapidly and intervene with target-specific management to reduce IAP.Surgical decompression followed by temporary abdominal closure should be considered in all patients with signs of organ dysfunction.There is still a great need for more studies to determine the adequate timing for interventions to improve patient outcomes.

Embryonic natural orifice transluminal endoscopic surgery in the treatment of severe acute pancreatitis complicated by abdominal compartment syndrome

BACKGROUND: The study aimed to estimate the value of embryonal natural orifice transluminal endoscopic surgery(ENOTES) in treating severe acute pancreatitis(SAP) complicated with abdominal compartment syndrome(ACS).METHODS: The patients, who were randomized into an ENOTES group and an operative group, underwent ENOTES and laparotomy, respectively. The results and complications of the two groups were compared.RESULTS: Enterocinesia was observed earlier in the ENOTES group than in the operative group. Acute Physiology and Chronic Health Evaluation II(APACHE II) score of patients in the ENOTES group was lower than that of the operative group on the 1st, 3rd and 5th post-operative day(P<0.05). The cure rate was 96.87% in the ENOTES group, which was statistically different from 78.12% in the operative group(P<0.05). There were significant differences in complications and mortality between the two groups(P<0.01).CONCLUSION: Compared with surgical decompression, ENOTES associated with flexible endoscope therapy is an effective and minimal invasive procedure with less complications.

Rare case of compartment syndrome provoked by inhalation of polyurethane agent:A case report

BACKGROUND The most common causes of compartment syndrome in the lower extremities include lower limb fractures,trauma-induced crushing injuries,severe burns,and non-traumatic factors.However,there have been no reports of compartment syndrome secondary to toxic inhalation.CASE SUMMARY A 59-year-old man,who lost consciousness after applying polyurethane-based paint on a water tank,was brought to the emergency room.The initial blood test showed apparent rhabdomyolysis.One day later,pain and swelling in both legs were observed,and the physical examination confirmed the presence of compartment syndrome.Double-incision fasciotomy was performed on both legs.Frequent dressings and negative pressure wound treatment were done on both legs,and skin grafting was performed after healthy granulation tissue had been identified.No other complications were observed after treatment.However,symptoms of peroneal neuropathy,particularly limited ankle dorsiflexion and reduced sensation on the lower extremities,were observed.CONCLUSION Workers using polyurethane agents should wear gas masks and be evaluated for compartment syndrome and rhabdomyolysis secondary to toxic inhalation.

Forearm compartment syndrome due to acquired hemophilia that required massive blood transfusions after fasciotomy:A case report

BACKGROUND Acquired hemophilia is rare.In some cases,the bleeding in muscle causes compartment syndrome.However,it is not clear whether fasciotomy should be performed for the compartment syndrome caused by acquired hemophilia because of the risk of bleeding and the unknown functional results.CASE SUMMARY A 75-year-old woman was admitted with severe pain of the right forearm with no preceding traumatic event.The right forearm was obviously swollen,and stretch pain was observed.Subcutaneous hematomas were suspected in various parts of the body.Compartment pressure was 110 mmHg on the volar side.Activated partial thromboplastin time(aPTT)was prolonged to 54.9 s.Fasciotomy was performed,and hematoma was observed in the volar compartment.Postoperative laboratory examinations revealed a low level of factor Ⅷ(FⅧ)activity(12.5%)and a high level of FⅧ inhibitor(15.2 bethesda units/mL).Acquired hemophilia A was diagnosed.Though recombinant clotting factors were administered,transfusion of red blood cells reached 46 units(140 mL/unit).Hemostasis was achieved 9 d after fasciotomy.The total cost of the clotting factor concentrates administered reached 28834600 yen.With prednisolone,FⅧ activity and aPTT recovered gradually.Final function of the hand was good in the index finger and excellent in the others.CONCLUSION Fasciotomy resulted in good function of the hand in a case of non-traumatic compartment syndrome caused by acquired hemophilia,but life-threatening bleeding occurred,and the cost of clotting factor treatment was high.Preparation of sufficient blood transfusion,preoperative administration of recombinant activated clotting factor Ⅶ,and prompt fasciotomy could be ideal for such cases.

Symptomatic accessory soleus muscle:A cause for exertional compartment syndrome in a young soldier:A case report

BACKGROUND Accessory soleus muscle(ASM)is a rare congenital variation that is almost asymptomatic,but several papers have recently described symptomatic ASM.The clinical features of this condition are similar to tarsal tunnel syndrome(TTS)and include pain and numbness around the medial side of the ankle.ASM commonly originates from the fibula or soleus muscle and inserts into the Achilles tendon or calcaneus.Usually,it is identified as posteromedial swelling and definitely diagnosed by magnetic resonance imaging.In most cases,treatment is observation,but surgical excision can be considered if symptoms are severe.CASE SUMMARY A 23-year-old male Korean soldier presented with complaints of bilateral foot and ankle pain and a swelling medial to the Achilles tendon that was more pronounced on the right side.Symptoms first occurred after playing soccer 10 mo before this presentation,worsened after physical exertion,and were relieved by rest.He had no medical history,and no one in his family had the condition.Laboratory results were non-specific.Several tests were performed to exclude common diseases such as tumors or TTS.However,MRI revealed a bulky accessory soleus muscle in both feet,though the patient complained of more severe pain on the right side during physical activity.Accordingly,surgical resection was adopted.At surgery,a large accessory soleus muscle was noted anterior to the Achilles tendon with distinctive insertion from a normal soleus muscle.At 12 mo after surgery,there was no pain,numbness,or swelling of the right foot or ankle,no evidence of recurrence,and the patient could do all sports activities.CONCLUSION Accessory soleus muscle should be added to the list of differential diagnosis if a patient has pain,sole numbness or swelling of the posteromedial ankle.

Atraumatic Acute Compartment Syndrome in Isolated Medial Compartment of Foot, A Rare Case Report

Acute compartment syndrome usually occurs after a traumatic event, typically in association with a fracture, but also from a soft tissue injury such as a direct blow or crush. Acute, isolated, medial compartment syndrome of the foot without a specific major trauma is very rare. I am reporting a rare case with acute compartment syndrome for isolated medial compartment of foot after a traumatic sport event and proper management to prevent long term sequels.

Anterior Compartment Syndrome after an Achilles Tendon Repair: A Case Report

Compartment syndrome may cause irreversible dysfunction if not treated correctly. The occurrence of compartment syndrome is not recognized as a potential complication after Achilles tendon rupture, and only a small number of such cases have been reported. We report the case of a 16-year-old girl with rupture of the right Achilles tendon. On postoperative day 4, she experienced severe anterior ankle pain. A blood test revealed a creatine kinase level of 7976 IU/L;the pressure in the distal anterior compartment was 90 mmHg and proximal compartment was 40 mmHg (needle manometer method). Magnetic resonance imaging (MRI) revealed a signal change in the anterior compartment. Anterior compartment syndrome was diagnosed on the basis of clinical findings, pressure measurements, and MRI findings. Emergency surgery was performed, and the anterior fascia was released. However, the dysfunction in the form of limited range of ankle motion remained. The cause of the compartment syndrome after Achilles tendon rupture was unclear. The patient’s involvement in basketball and positioning of the ankle in plantar flexion with a cast might have been contributing factors in our case. We need to consider the possibility that compartment syndrome may occur after Achilles tendon rupture.

First Reported Incidence of Delayed Secondary Abdominal Compartment Syndrome in a Trauma Patient with Scleroderma: A Case Report and Review of the Literature

Background: Scleroderma is a complex immune-mediated rheumatic disease that is characterized by fibrosis of the skin, internal organs, and vasculopathy. Extensive fibrosis, especially in the limited compartment, has been reported to induce acute compartment syndrome frequently reported involving the upper and lower extremities. Case Presentation: We present a rare case of a 54-year-old Caucasian female who underwent surgery for abdominal compartment syndrome in the setting of scleroderma. Upon arrival, at the hospital, the patient’s health status showed signs of improvement with no indicators of abdominal compartment syndrome until the tenth hospital day. A CT scan showed a new intra-abdominal fluid collection with total lower abdominal anasarca and a stable retroperitoneal hematoma. Following emergency surgery, significant bowel edema without other intra-abdominal injuries was noted. Conclusion: Secondary abdominal compartment syndrome may occur in patients with scleroderma without evidence of intra-abdominal trauma or emergent abdominal surgery. Further research is warranted to investigate the relationship between scleroderma and secondary abdominal compartment syndrome.

Hemorrhoid sclerotherapy with the complication of abdominal compartment syndrome： report of a case

The complications of injection sclerotherapy for hemorrhoid are always local. Herein, we report a case in which a female patient with abdominal compartment syndrome developed after receiving a local injection of a sclerosing agent for hemorrhoid.

Pelvic compartment syndrome caused by retroperitoneal hematoma of pelvic fracture

Retroperitoneal hematoma is an obligatory complication in pelvic ring fracture.~1 In most cases, the bleeding originates from venous vessels of the presacral plexus, small arteries and veins from fracture fragments. External fixation of the pelvis can control blood loss by reducing diastasis and dramatically decreasing the volume of the pelvis. But this tamponade effect can not prevent the presence of hematoma in the adjoining retroperitoneal space. It is well known that complication of retroperitoneal hematoma is infection and sepsis.

Epstein-Barr virus associated secondary hemophagocytic lymphohistiocytosis with an unusual presentation of abdominal compartment syndrome

Hemophagocytic lymphohistiocytosis(HLH)is a cytokine storm syndrome caused by an overactive but ineffective immune reaction.Without prompt diagnosis and treatment,HLH is life-threatening.However,presenting symptoms are often nonspecific,with fatigue and fever being the most common.A high index of suspicion is therefore critical for early diagnosis and timely management.A previously healthy,65-year-old female who initially presented with fever and abdominal pain developed abdominal compartment syndrome(ACS)requiring decompressive laparotomy on hospital day 6.Intraoperative frozen sections of biopsied liver showed intense portal lymphohistiocytic infiltrates.Epstein-Barr virus DNA copy numbers escalated from 600 copies/mL after admission to 134,000 copies/mL before death.The diagnostic criteria of HLH-2004 were met.Patient expired on hospital day 12.It is important to raise awareness of ACS being an unusual presentation of HLH.Recent changes in diagnostic criteria tailored to adult HLH cases are reviewed.

Should we perform decompressive laparotomy during severe acute pancreatitis with intra-abdominal hypertension below 25 mmHg:Only the gut knows

We suggest that during severe acute pancreatitis(SAP)with intra-abdominal hypertension,practitioners should consider decompressive laparotomy,even with intra-abdominal pressure(IAP)below 25 mmHg.Indeed,in this setting,non-occlusive mesenteric ischemia(NOMI)may occur even with IAP below this cutoff and lead to transmural necrosis if abdominal perfusion pressure is not promptly restored.We report our experience of 18 critically ill patients with SAP having undergone decompressive laparotomy of which one third had NOMI while IAP was mostly below 25 mmHg.

Derivation of a Standardized Method to Identify the Anterior Compartment of the Lower Extremity Using Point-of-Care Ultrasonography

Introduction: Anterior compartment syndrome (ACS) of the lower extremity is a well-recognized surgical emergency. The anterior compartment is the most frequently missed of the four compartments during lower extremity fasciotomy. This study describes a novel approach that combines sonographic measurements and physical examination landmarks to accurately identify the anterior compartment. Materials and Methods: This study was conducted as a prospective anatomical study of 94 volunteers at a single institution. Physical exam and sonographic methods were utilized to derive measurements of the anterior compartment, followed by biometric and validation data. Results: Volunteers for the derivation and validation phases of study were similar regarding gender, height and weight, age, and BMI. The derivation set revealed the distance to the anterior compartment to be 2.77 cm (median 2.6 cm, range 1.5 - 5.4 cm) from the mid-axial line and resulted in identification of the anterior compartment 100% of the time (p < 0.001). Findings were reproducible in the internal validation set with 100% accuracy. Conclusion: The fascial planes of the anterior compartment can be identified with 100% accuracy when utilizing physical examination and sonographic methods. This can serve as a foundation for future studies evaluating ways to reduce of the number of missed anterior compartment fasciotomies in the setting of ACS.