Continuous regional arterial infusion and laparotomic decompression for severe acute pancreatitis with abdominal compartment syndrome

AIM:To evaluate the therapeutic effects of abdominal decompression plus continuous regional arterial infusion(CRAI) via a drug delivery system(DDS) in severe acute pancreatitis(SAP) patients with abdominal compartment syndrome(ACS).METHODS:We presented our recent experience in 8 patients with SAP.The patients developed clinical ACS,which required abdominal decompression.During the operation,a DDS was inserted into the peripancreatic artery(the catheter was inserted from the right gastroepiploic artery until it reached the junction between the pancreaticoduodenal and gastroduodenal artery).Through this DDS,a protease inhibitor,antibiotics and octreotide were infused continuously.The duration of the regional artery infusion ranged from 8 to 41 d.The outcomes and the changes in the APACHE Ⅱ score,computed tomography(CT) severity index and intraabdominal pressure(IAP) of the patients were retrospectively evaluated.RESULTS:Eight patients with an initial APACHE Ⅱ score of 18.9(range,13-27) and a Balthazar CT severity index of 9.1(range,7-10) developed severe local and systemic complications.These patients underwent subsequent surgical decompression and CRAI therapy because of intra-abdominal hypertension(IAH).After a mean interval of 131.9 ± 72.3 d hospitalization,7 patients recovered with decreased APACHE Ⅱ scores,CT severity indexes and IAP.The mean APACHE Ⅱ score was 5.4(range,4-8),the CT severity index was 2.3(range,1-3),and IAP decreased to 7.7 mmHg(range,6-11 mmHg) 60 d after operation.One patient died of multiple organ failure 1 wk after surgery.CONCLUSION:CRAI and laparotomic decompression might be a therapeutic option for SAP patients with ACS.

EARLY SURGERY TO PATIENTS SUFFERING FULMINANT ACUTE PANCREATITIS WITH ABDOMINAL COMPARTMENT SYNDROME

Objective To retrospectively analyze and compare conservative versus surgical treatment of patients with fulminant acute pancreatitis (FAP) plus abdominal compartment syndrome (ACS). Methods From January 1998 to September 2005, 21 patients with FAP plus ACS were retrospectively analyzed. Ten patients were conservatively treated by means of intensive care medicine without surgery, and 11 patients received open surgical management and suction drainage. Results Seven of the 10 non-surgical patients died, comprising one with mild, four with moderate and two with severe ACS (70% mortality rate). Of the 11 patients receiving open surgical management in the early phase (within 3 days of disease initiation), three died, comprising one with moderate and two with severe ACS (27.3% mortality rate). The difference in mortality rates was found to be statistically significant. Conclusion Our data indicate patients suffering FAP with severe ACS should be treated with open management of the abdomen in the early phase (within 3 days), even in the absence of infection. This approach appears superior to that of conservative management. Surgical treatment resulted in abdominal decompression and subsequently significantly decreased the mortality rate and improved overall prognosis.

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.