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.

Preoperative blood markers and intra-abdominal infection after colorectal cancer resection

BACKGROUND Colorectal cancer(CRC)has one of the highest morbidity and mortality rates among digestive tract tumors.Intra-abdominal infection(IAI)is a common postoperative complication that affects the clinical outcomes of patients with CRC and hinders their rehabilitation process.However,the factors influencing abdominal infection after CRC surgery remain unclear;further,prediction models are rarely used to analyze preoperative laboratory indicators and postoperative complications.AIM To explore the predictive value of preoperative blood markers for IAI after radical resection of CRC.METHODS The data of 80 patients who underwent radical resection of CRC in the Anorectal Surgery Department of Suzhou Hospital affiliated with Anhui Medical University were analyzed.These patients were categorized into IAI(n=15)and non-IAI groups(n=65)based on whether IAI occurred.Influencing factors were compared;general data and laboratory indices of both groups were identified.The relationship between the indicators was assessed.Further,a nomogram prediction model was developed and evaluated;its utility and clinical applic-ability were assessed.RESULTS The risk factors for IAI after radical resection of CRC were neutrophil-lymphocyte ratio(NLR),platelet-lymphocyte ratio(PLR),systemic immune-inflammation index(SII),and carcinoembryonic antigen(CEA)levels.NLR was correlated with PLR and SII(r=0.604,0.925,and 0.305,respectively),while PLR was correlated with SII(r=0.787).The nomogram prediction model demonstrated an area under the curve of 0.968[95%confidence interval(CI):0.948-0.988]in the training set(n=60)and 0.926(95%CI:0.906-0.980)in the validation set(n=20).The average absolute errors of the calibration curves for the training and validation sets were 0.032 and 0.048,respectively,indicating a good model fit.The decision curve analysis curves demonstrated high net income above the 5%threshold,indicating the clinical practicality of the model.CONCLUSION The nomogram model constructed using NLR,PLR,SII,and CEA levels had good accuracy and reliability in predicting IAI after radical resection of CRC,potentially aiding clinical treatment decision-making.

Causative Microorganisms Isolated from Patients with Intra-Abdominal Infections and Their Drug Resistance Profiles:An 11-Year(2011–2021)Single-Center Retrospective Study

Objective To investigate the distribution and antimicrobial susceptibility of causative microorganisms recovered from patients with intra-abdominal infections(IAIs).Methods A total of 2,926 bacterial and fungal strains were identified in samples collected from 1,679 patients with IAIs at the Peking Union Medical College Hospital between 2011 and 2021.Pathogenic bacteria and fungi were identified using matrix-assisted laser desorption/ionization time-of-flight mass spectrometry.Antimicrobial susceptibility testing(AST)was performed using the VITEK 2 compact system and the Kirby–Bauer method.AST results were interpreted based on the M100-Ed31 clinical breakpoints of the Clinical and Laboratory Standards Institute.Results Of the 2,926 strains identified,49.2%,40.8%,and 9.5%were gram-negative bacteria,gram-positive bacteria,and fungi,respectively.Escherichia coli was the most prevalent pathogen in intensive care unit(ICU)and non-ICU patients;however,a significant decrease was observed in the isolation of E.coli between 2011 and 2021.Specifically,significant decreases were observed between 2011 and 2021 in the levels of extended-spectrumβ-lactamase(ESBL)-producing E.coli(from 76.9%to 14.3%)and Klebsiella pneumoniae(from 45.8%to 4.8%).Polymicrobial infections,particularly those involving co-infection with gram-positive and gram-negative bacteria,were commonly observed in IAI patients.Moreover,Candida albicans was more commonly isolated from hospital-associated IAI samples,while Staphylococcus epidermidis had a higher ratio in community-associated IAIs.Additionally,AST results revealed that most antimicrobial agents performed better in non-ESBL-producers than in ESBL-producers,while the overall resistance rates(56.9%–76.8%)of Acinetobacter baumanmii were higher against all antimicrobial agents than those of other common gram-negative bacteria.Indeed,Enterococcus faecium,Enterococcus faecalis,S.epidermidis,and S.aureus were consistently found to be susceptible to vancomycin,teicoplanin,and linezolid.Similarly,C.albicans exhibited high susceptibility to all the tested antifungal drugs.Conclusion The distribution and antimicrobial susceptibility of the causative microorganisms from patients with IAls were altered between 2011 and 2021.This finding is valuable for the implementation of evidence-based antimicrobial therapy and provides guidance for the control of hospital infections.

Timing of surgical operation for patients with intra-abdominal infection:A systematic review and meta-analysis

BACKGROUND Intra-abdominal infections(IAIs)is the most common type of surgical infection,with high associated morbidity and mortality rates.In recent years,due to the use of antibiotics,various drug-resistant bacteria have emerged,making the treatment of abdominal infections more challenging.Early surgical exploration can reduce the mortality of patients with abdominal infection and the occurrence of complications.However,available evidence regarding the optimal timing of IAI surgery is still weak.In study,we compared the effects of operation time on patients with abdominal cavity infection and tried to confirm the best timing of surgery.AIM To assess the efficacy of early vs delayed surgical exploration in the treatment of IAI,in terms of overall mortality.METHODS A systematic literature search was performed using PubMed,EMBASE,Cochrane Central Register of Controlled Trials,Ovid,and ScienceDirect.The systematic review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-analyses method.Based on the timing of the surgical operation,we divided the literature into two groups:Early surgery and delayed surgery.For the early and delayed surgery groups,the intervention was performed with and after 12 h of the initial surgical intervention,respectively.The main outcome measure was the mortality rate.The literature search was performed from May 5 to 20,2021.We also searched the World Health Organization International Clinical Trials Registry Platform search portal and ClinicalTrials.gov on May 20,2021,for ongoing trials.This study was registered with the International Prospective Register of Systematic Reviews.RESULTS We identified nine eligible trial comparisons.Early surgical exploration of patients with IAIs(performed within 12 h)has significantly reduced the mortality and complications of patients,improved the survival rate,and shortened the hospital stay.CONCLUSION Early surgical exploration within 12 h may be more effective for the treatment of IAIs relative to a delayed operation.

Elevated intra-abdominal pressure:A review of current knowledge

Elevated intra-abdominal pressure(IAP)is a known cause of increased morbidity and mortality among critically ill patients.Intra-abdominal hypertension(IAH)and abdominal compartment syndrome can lead to rapid deterioration of organ function and the development of multiple organ failure.Raised IAP affects every system and main organ in the human body.Even marginally sustained IAH results in malperfusion and may disrupt the process of recovery.Yet,despite being so common,this potentially lethal condition often goes unnoticed.In 2004,the World Society of the Abdominal Compartment Syndrome,an international multidisciplinary consensus group,was formed to provide unified definitions,improve understanding and promote research in this field.Simple,reliable and nearly costless standardized methods of non-invasive measurement and monitoring of bladder pressure allow early recognition of IAH and timely optimized management.The correct,structured approach to treatment can have a striking effect and fully restore homeostasis.In recent years,significant progress has been made in this area with the contribution of surgeons,internal medicine specialists and anesthesiologists.Our review focuses on recent advances in order to present the complex underlying pathophysiology and guidelines concerning diagnosis,monitoring and treatment of this life-threatening condition.

Study of intra-abdominal hypertension prevalence and awareness level among experienced ICU medical staff

Background:Intra-abdominal hypertension(IAH) is a disease with high morbidity and mortality among critically ill patients.The study's objectives were to explore the prevalence of IAH and physicians' awareness of the 2013 World Society of Abdominal Compartment Syndrome(WSACS) guidelines in Chinese intensive care units(ICUs).Methods:A cross-sectional study of four ICUs in Southwestern China was conducted from June 17 to August 2,2014.Adult patients admitted to the ICU for more than 24 h,with bladder catheter but without obvious intravesical pressure(IVP) measurement contraindications,were recruited.Intensivists with more than 5 years of ICU working experience were also recruited.Epidemiological information,potential IAH risk factors,IVP measurements and questionnaire results were recorded.Results:Forty-one patients were selected.Fifteen(36.59%) had IVP?12mm Hg.SOFA(Sequential Organ Failure Assessment) hepatic and neurological sub-scores were utilized as independent predictors for IAH via logistic backward analysis.Thirty-seven intensivists participated in the survey(response rate:80.43%).The average score of each center was less than 35 points.All physicians believed the IAH prevalence in their departments was no more than 20.00%.A significant negative correlation was observed between the intensivists' awareness of the 2013 WSACS guidelines and the IAH prevalence in each center(r=-0.975,P=0.025).Conclusion:The prevalence and independent predictors of IAH among the surveyed population are similar to the reports in the literature.Intensivists generally have a low awareness of the 2013 WSACS guidelines.A systematic guideline training program is vital for improving the efficiency of the diagnosis and treatment of IAH.

Poor oncologic outcomes of hepatocellular carcinoma patients with intra-abdominal infection after hepatectomy

AIM: To evaluate the impact of postoperative infectious complications on hepatocellular carcinoma following curative hepatectomy.METHODS:We performed a retrospective analysis of200 hepatocellular carcinoma patients who underwent hepatectomy at our institution between September2003 and June 2011.The patients’demographics,clinicopathological characteristics and postoperative infectious complications were analyzed.The ClavienDindo classification was adopted to assess the severity of complications.The dynamic change in the neutrophilto-lymphocyte ratio,defined as the absolute neutrophil count divided by the absolute lymphocyte count,after surgery was also investigated.The observation endpoints for this study were recurrence-free survival and overall survival of the patients.Statistical analysis of the survival curves was performed using the KaplanMeier method and the log-rank test.The prognosticvalue of each variable for predicting prognosis was assessed via multivariate Cox proportional hazards regression analysis.The cutoff score for each variable was selected based on receiver operating characteristic curve analysis.All statistical tests were two-sided,and significance was set at P<0.05.RESULTS:The median age of the patients was 49years,and the majority of patients were male(86%)and had been infected with hepatitis B virus(86%).The 30-d postoperative infectious complication rate was34.0%(n=68).Kaplan-Meier survival analysis revealed that postoperative infection was significantly correlated with tumor recurrence(P<0.001).The postoperative intra-abdominal infection group exhibited a worse prognosis than the non-intra-abdominal infection group(P<0.001).A significantly increased incidence of postoperative intra-abdominal infection was observed in the patients with hepatic cirrhosis(P=0.028),concomitant splenectomy(P=0.007)or vascular invasion(P=0.026).The patients who had an elevated postoperative neutrophil-to-lymphocyte ratio change(>1.643)clearly exhibited poorer recurrence-free survival than those who did not(P=0.009),although no significant correlation was observed between overall survival and the change in the postoperative neutrophilto-lymphocyte ratio.Based on multivariate analysis,hepatitis B surface antigen positivity,Child-TurcottePugh class B,an elevated postoperative neutrophilto-lymphocyte ratio change and intra-abdominal infection were significant predictors of poor recurrencefree survival.Hepatic cirrhosis,the maximal tumor diameter and intra-abdominal infection were significant predictors of overall survival.CONCLUSION:Postoperative intra-abdominal infection adversely affected oncologic outcomes,and the change in postoperative neutrophil-to-lymphocyte ratio was a good indicator of tumor recurrence in hepatocellular carcinoma patients after curative hepatectomy.

Intra-abdominal pressure:Time ripe to revise managementguidelines of acute pancreatitis?

AIM: To systematically review evidence on pathophysiology of intra-abdominal pressure(IAP) in acute pancreatitis(AP) with its clinical correlates. METHODS: Systematic review of available evidence in English literature with relevant medical subject heading terms on Pub Med, Medline and Scopus with further search from open access sources on internet as suggested by articles retrieved. RESULTS: Intra-abdominal hypertension(IAH) is increasingly gaining recognition as a point of specific intervention with potential to alter disease outcome and improve mortality in AP. IAH can be expected in at least 17% of patients presenting with diagnosis of AP to a typical tertiary care hospital(prevalence increasing to 50% in those with severe disease). Abdominal compartment syndrome can be expected in at least 15% patients with severe disease. Recent guidelines on management of AP do not acknowledge utility of surveillance for IAP other than those by Japanese Society of Hepato-BiliaryPancreatic Surgery. We further outline pathophysiologic mechanisms of IAH; understanding of which advances our knowledge and helps to coherently align common observed variations in management related conundrums(such as fluid therapy, nutrition and antibiotic prophylaxis) with potential to further individualize treatment in AP. CONCLUSION: We suggest that IAP be given its due place in future practice guidelines and that recommendations be formed with help of a broader panel with inclusion of clinicians experienced in management of IAH.

Risk factors of intra-abdominal bacterial infection after liver transplantation in patients with hepatocellular carcinoma

Objective： To explore the risk factors of intra-abdominal bacterial infection （IAI） after liver transplantation （LT） in patients with hepatocellular carcinoma （HCC）. Methods： A series of 82 HCC patients who received LT surgeries in our department between March 2004 and April 2010 was recruited in this study. Then we collected and analyzed the clinical data retrospectively. Statistical analysis system （SPSS） software was adopted to perform statistical analysis. Chi-square test, t-test and Wilcoxon rank sum test were used to analyze the clinical data and compute the significance of the incidences of early-stage IAI after LT for HCC patients. Binary logistic regression was performed to screen out the risk factors, and multiple logistic regression analyses were performed to compute the independent risk factors. Results： A series of 13 patients （13/82, 15.9%） had postoperative IAI. The independent risk factors of postoperative intra-abdominal bacterial infections after LT for HCC patients were preoperative anemia [Hemoglobin （HGB） 〈90 g/L] and postoperative abdominal hemorrhage （72 hours 〉400 mL）, with the odds ratios at 8.121 （95% CI, 1.417 to 46.550, P=0.019） and 5.911 （95% CI, 1.112 to 31.432, P=0.037）. Conclusions： Postoperative IAI after LT in patients with HCC was a common complication. Preoperative moderate to severe anemia, as well as postoperative intra-abdominal hemorrhage more than 400 mL within the first 72 hours might independently indicate high risk of IAI for these patients.

Endoscopic ultrasound-guided drainage of postoperative intra-abdominal abscesses

Although endoscopic ultrasound(EUS)-guided drainage has become the standard procedure for pancreatic pseudocysts in recent years and is generally regarded as a safe and effective method,there have been few reports of EUS-guided drainage of postoperative intra-abdominal abscesses.Here we report our experience with 4 cases of postoperative intraabdominal abscesses for which EUS-guided drainage was performed between May 2011 and May 2014.Distal pancreatectomy had been performed in 3 cases,whereas low anterior resection for rectal cancer was performed in the remaining case.All patients underwent transgastric naso-cystic drainage,which resulted in clinical improvement without complications,even when performed within 4 wk after surgery.On average,the naso-cystic drain was removed 10 d after placement,with no abscess recurrence.Based on these findings,we believe that EUS-guided drainage of postoperative intraabdominal abscesses is a safe and effective method,although further large-scale investigations are required to confirm our findings.

Intra-abdominal pressure monitoring in predicting outcome of patients with severe acute pancreatitis

BACKGROUND: Severe acute pancreatitis (SAP) is a serious disease with many complications, high mortality and poor prognosis. It is characterized by rapid deterioration and poses one of the most difficult challenges in clinical practice. Previous investigations suggest that SAP is one of the main causes of intra-abdominal pressure (IAP) increase. The aim of this study was to evaluate the utility of IAP-monitoring in predicting the severity and prognosis of SAP. METHODS: Eighty-nine patients with SAP who had been treated from February 2001 to December 2005 were studied. Since bladder pressure accurately reflects IAP, we measured it instead of IAP. Bladder pressure was measured at the time of admission and every 12 hours in the course of the disease, 9 consecutive times in all. The APACHE II scores of all patients were obtained within 24 hours after admission. According to a maximum bladder pressure <10 cmH(2)O, all patients were divided into two groups, mildly-elevated and severely-elevated. Mortality and mean APACHE II scores in the two groups were calculated. In addition, the mean bladder pressure and APACHE II scores in survivors were compared with those in deaths. RESULTS: Sixty-eight of the 89 patients were in the severely-elevated group. Mortality and mean APACHE II scores in this group were much higher than those in the mildly-elevated group (mortality, 39.71% vs. 9.52%; mean APACHE II score, 23.15 +/- 7.42 vs. 15.95 +/- 5.35, P<0.01). The mean bladder pressures and APACHE II scores in deaths were significantly greater than those in survivors (mean bladder pressure, 14.1 +/- 3.8 vs. 9.2 +/- 2.3 cmH(2)O, P<0.01; mean APACHE II score, 27.83 +/- 4.87 vs. 18.37 +/- 6.74, P<0.01). CONCLUSION: It is suggested that IAP may be used as a marker of the severity and prognosis of SAP.

Effect of intra-abdominal volume increment on kidneys in minipigs with intra-abdominal hypertension after hemorrhagic shock and resuscitation

Background: To investigate the effect of intra-abdominal volume increment(IAVI) on intra-abdominal hypertension(IAH) in the kidneys.Methods: Eight minipigs were successfully established as IAH models and were randomly divided into two groups: the IAVI group and the sham-operated group. The intravesical pressure, inferior vena cava pressure and urine volume were measured before shock, 2 h after IAH, and 22 h after surgery, respectively. The following indices were measured: serum creatinine, urea nitrogen, renal cortical thickness, ratio of abdominal anteroposterior diameter/transverse diameter, renal thickness, diameter of the renal sinus and the wet/dry ratio of renal tissues.Results: The intravesical pressure(IVP) of the 8 minipig IAH models was calculated to be 21.16±4.63 mmHg. There was a significant increase in the abdominal anteroposterior diameter/transverse diameter ratio. The minipigs in the IAVI group survived during the observational period, whereas 2 minipigs died at 18 h and 20 h in the sham-operated group. Twenty-two hours after surgery, the animals in the IAVI group displayed increased urinary volume(UV) and decreased Cr and Ur and remarkable decreases of VP and IVCP. After IAH, the renal cortical thickness and the renal thickness increased significantly. The renal wet/dry ratio in the sham-operated group was higher than that in the IAVI group.Conclusion: IAVI helps to control renal dysfunction after IAH, which may be related to lowering the intra-abdominal pressure, thus alleviating renal edema and blood stasis.

The effect of increased intra-abdominal pressure on orbital subarachnoid space width and intraocular pressure

In accordance with the trans-lamina cribrosa pressure difference theory, decreasing the trans-lamina cribrosa pressure difference can re- lieve glaucomatous optic neuropathy. Increased intracranial pressure can also reduce optic nerve damage in glaucoma patients, and a safe, effective and noninvasive way to achieve this is by increasing the intra-abdominal pressure. The purpose of this study was to observe the changes in orbital subarachnoid space width and intraocular pressure at elevated intra-abdominal pressure. An inflatable abdominal belt was tied to each of 15 healthy volunteers, aged 22-30 years （12 females and 3 males）, at the navel level, without applying pressure to the abdomen, before they laid in the magnetic resonance imaging machine. The baseline orbital subarachnoid space width around the optic nerve was measured by magnetic resonance imaging at 1, 3, 9, and 15 mm behind the globe. The abdominal belt was inflated to increase the pressure to 40 mmHg （1 mmHg = 0.133 kPa）, then the orbital subarachnoid space width was measured every 10 minutes for 2 hours. After removal of the pressure, the measurement was repeated 10 and 20 minutes later. In a separate trial, the intraocular pressure was measured for all the subjects at the same time points, before, during and after elevated intra-abdominal pressure. Results showed that the baseline mean orbital subarachnoid space width was 0.88 ＋ 0.1 mm （range： 0.77-1.05 mm）, 0.77 ＋ 0.11 mm （range： 0.60-0.94 mm）, 0.70 ＋ 0.08 mm （range： 0.62-0.80 ram）, and 0.68 _＋ 0.08 mm （range： 0.57-0.77 mm） at 1, 3, 9, and 15 mm behind the globe, respectively. During the elevated intra-abdominal pressure, the orbital subarachnoid space width increased from the baseline and dilation of the optic nerve sheath was significant at 1, 3 and 9 mm behind the globe. After decompression of the abdominal pressure, the orbital subarachnoid space width normalized and returned to the baseline value. There was no significant difference in the intraocular pressure before, during and after the intra-abdominal pressure elevation. These results verified that the increased intra-abdominal pressure widens the orbital subarachnoid space in this acute trial, but does not alter the intraocular pressure, indicating that intraocular pressure is not affected by rapid increased in- tra-abdominal pressure. This study was registered in the Chinese Clinical Trial Registry （registration number： ChiCTR-ONRC-14004947）.

Mild to moderate intra-abdominal hypertension: Does it matter?

This review summarizes the epidemiology, pathophysiological consequences and impact on outcome of mild to moderate(Grade Ⅰ to Ⅱ) intra-abdominal hypertension(IAH), points out possible pitfalls in available treatment recommendations and focuses on tasks for future research in the field. IAH occurs in about 40% of ICU patients. Whereas the prevalence of abdominal compartment syndrome seems to be decreasing, the prevalence of IAH does not. More than half of IAH patients present with IAH grade Ⅰ and approximately a quarter with IAH grade Ⅱ. However, most of the studies have addressed IAH as a yes-or-no variable, with little or no attention to different severity grades. Even mild IAH can have a negative impact on tissue perfusion and microcirculation and be associated with an increased length of stay and duration of mechanical ventilation. However, the impact of IAH and its different grades on mortality is controversial. The influence of intra-abdominal pressure(IAP) on outcome most likely depends on patient and disease characteristics and the concomitant macro- and microcirculation. Therefore, management might differ significantly. Today, clear triggers for interventions in different patient groups with mild to moderate IAH are not defined. Further studies are needed to clarify the clinical importance of mild to moderate IAH identifying clear triggers for interventions to lower the IAP.

Clinical and Microbiological Characteristics of Patients with Complicated Intra-abdominal Infections in Intensive Care Unit

In order to investigate the clinical and microbiological characteristics of patients with complicated intra-abdominal infections(cIAIs)in intensive care unit(ICU),the clinical data of 612 cIAIs patients from January 2016 to December 2018 were retrospectively collected.Clinical characteristics,distribution of pathogens and drug resistance were statistically analyzed.It was found that patients with community-acquired intra-abdominal infections(CA-IAIs)made up a majority of cIAIs patients.The positive rate of abdominal drainage fluid culture was 55.56%.Gramnegative bacteria accounted for the majority,the most commonly isolated bacteria of which were Escherichia coli(20.96%),Klebsiella pneumoniae(10.20%)and Pseudomonas aeruginosa(5.57%).The most commonly isolated gram-positive bacteria were Enterococcus(16.88%)and Methicillinresistant staphylococcus aureus(MRSA,3.90%).Enterobacter isolates showed high resistance rate to most cephalosporins and low resistance rate to piperacillin/tazobactam and carbapenems.Extended spectrum beta-lactamase(ESBL)screen positive isolates from CA-IAIs patients showed an increasing trend in past three years.Enterococcus and MRSA showed high resistance rate to clindamycin,quinolone,erythromycin and tetracycline,while they showed high sensitivity rate to linezolid,tegacycline,teicoplanin and vancomycin.Our results indicate that isolated bacteria from abdominal drainage fluid show high resistance rates to commonly used antibiotics in ICU patients with cIAIs.The curative effects on diseases should be monitored continuously when antibiotics are used.Meanwhile,we should always keep eyes on drug-resistant bacteria,especially when the treatment efficacy is not good.

Effect of intra-abdominal pressure on respiratory function in patients undergoing ventral hernia repair

AIM: To determine the influence of intra-abdominal pressure(IAP) on respiratory function after surgical repair of ventral hernia and to compare two different methods of IAP measurement during the perioperative period. METHODS: Thirty adult patients after elective repair of ventral hernia were enrolled into this prospective study.IAP monitoring was performed via both a balloontipped nasogastric probe [intragastric pressure(IGP), Ci MON, Pulsion Medical Systems, Munich, Germany] and a urinary catheter [intrabladder pressure(IBP), Uno Meter Abdo-Pressure Kit, Uno Medical, Denmark] on five consecutive stages:(1) after tracheal intubation(AI);(2) after ventral hernia repair;(3) at the end of surgery;(4) during spontaneous breathing trial through the endotracheal tube; and(5) at 1 h after tracheal extubation. The patients were in the complete supine position during all study stages.RESULTS: The IAP(measured via both techniques) increased on average by 12% during surgery compared to AI(P < 0.02) and by 43% during spontaneous breathing through the endotracheal tube(P < 0.01). In parallel, the gradient between РаСО2 and Et CO2 [Р(а-et)CO2] rose significantly, reaching a maximum during the spontaneous breathing trial. The PаO2/Fi O2 decreased by 30% one hour after tracheal extubation(P = 0.02). The dynamic compliance of respiratory system reduced intraoperatively by 15%-20%(P < 0.025). At all stages, we observed a significant correlation between IGP and IBP(r = 0.65-0.81, P < 0.01) with a mean bias varying from-0.19 mm Hg(2SD 7.25 mm Hg) to-1.06 mm Hg(2SD 8.04 mm Hg) depending on the study stage. Taking all paired measurements together(n = 133), the median IGP was 8.0(5.5-11.0) mm Hg and the median IBP was 8.8(5.8-13.1) mm Hg. The overall r2 value( n = 30) was 0.76(P < 0.0001). Bland and Altman analysis showed an overall bias for the mean values per patient of 0.6 mm Hg(2SD 4.2 mm Hg) with percentage error of 45.6%. Looking at changes in IAP between the different study stages, we found an excellent concordance coefficient of 94.9% comparing IBP and IGP( n = 117).CONCLUSION: During ventral hernia repair, the IAP rise is accompanied by changes in Р(а-et)CO2 and PаO2/Fi O2-ratio. Estimation of IAP via IGP or IBP demonstrated excellent concordance.

Intra-abdominal hemorrhage during pregnancy: Four case reports

BACKGROUND Intra-abdominal hemorrhage during pregnancy is a rare and dangerous complication of pregnancy.In this article,we report 4 cases of intra-abdominal hemorrhage during pregnancy,including the spontaneous rupture of uterine veins,spontaneous rupture of liver,rupture of external iliac vessel branch,and rupture of right renal hamartoma.CASE SUMMARY The clinical manifestations of three patients lacked specificity,and the localization of the bleeding was not clear prior to surgery.All 4 pregnant women were successfully treated,while only one full-term infant survived.CONCLUSION There are diverse causes of intra-abdominal hemorrhage during pregnancy in clinic,and it is clinically characterized by acute abdominal pain during pregnancy.Clear diagnosis before surgery is rather difficult.Early diagnosis,timely and appropriate treatment and surgery,and multidisciplinary cooperation are key to saving pregnant females’lives and improving the outcomes of perinatal infants.

Noninvasive monitoring of intra-abdominal pressure by measuring abdominal wall tension

BACKGROUND: Noninvasive monitoring of intra-abdominal pressure(IAP) by measuring abdominal wall tension(AWT) was effective and feasible in previous postmortem and animal studies. This study aimed to investigate the feasibility of the AWT method for noninvasively monitoring IAP in the intensive care unit(ICU).METHODS: In this prospective study, we observed patients with detained urethral catheters in the ICU of Shanghai Tenth People's Hospital between April 2011 and March 2013. The correlation between AWT and urinary bladder pressure(UBP) was analyzed by linear regression analysis. The effects of respiratory and body position on AWT were evaluated using the paired samples t test, whereas the effects of gender and body mass index(BMI) on baseline AWT(IAP<12 mm Hg) were assessed using one-way analysis of variance.RESULTS: A total of 51 patients were studied. A significant linear correlation was observed between AWT and UBP(R=0.986, P<0.01); the regression equation was Y=–1.369+9.57X(P<0.01). There were signif icant differences among the different respiratory phases and body positions(P<0.01). However, gender and BMI had no signif icant effects on baseline AWT(P=0.457 and 0.313, respectively).CONCLUSIONS: There was a signif icant linear correlation between AWT and UBP and respiratory phase, whereas body position had signif icant effects on AWT but gender and BMI did not. Therefore, AWT could serve as a simple, rapid, accurate, and important method to monitor IAP in critically ill patients.

Intra-abdominal desmoid tumor after liver transplantation: A case report

We are reporting the first documented case of an abdominal desmoid tumor presenting primarily after liver transplantation. This tumor, well described in the literature as occurring both in conjunction with familial adenomatous polyposis as well as in the postsurgical patient, has never been noted after solid organ transplantation and was therefore not included in our differential upon presentation. Definitive diagnosis required the patient to undergo surgical excision and immunochemical staining of the mass for confirmation. A review of the literature showed no primary tumors after transplantation. In a population of patients who received a small bowel transplant after they developedshort gut post radical resection of aggressive fibromatosis, only rare recurrences were seen. No connection of tumor development with immunosuppression or need to decrease immunosuppressant treatment has been demonstrated in these patients. Our case and the literature show the risk of this tumor presenting in the post-transplantation patient and the need for a high index of suspicion in patients who present with a complex mass after transplantation to prevent progression of the disease beyond a resectable lesion. Results of a thorough search of the literature are detailed and the medical and surgical management of both resectable and unresectable lesions is reviewed.

CHANGES OF PLASMA AMINO ACID IN TPN SUPPORTED PATIENTS WITH INTRA-ABDOMINAL INFECTION

The changes of plasma aminogram were observed prospectively on 95 cases of enteric fistula associated with intra-abdominal infection under the supplement of TPN(total parenteral nutrition) with a conventional balanced nutritional amino acid solution Anfumine 14s (8.5% Tianjin, China). Plasma levels of amino acid and albumin were determined on the day of initiation of TPN and weekly through the Course of nutritional support and the day of termination of TPN or 2-5 days within death. Initial plasma aminograms obtained on the day before the TPN support were of characterics of aminogram of both sepsis and starvation. The initial total amount of plasma free amino acid was lower than normal and gradually elevated to normal range after two weeks TPN supplement in survivors. While in nonsurvivors, the total free amino acid was increased rapidly and reached the peak value at preterminal stage, significantly higher than the normal range. The level of phenylalanine was constantly high through the course of investigation, either in survivors or nonsurvivors. Proline also elevated proportional to the severity of infection, but to a lesser degree In contrast, the plasma ratio of BCAA/AAA (branched-chain amino acids /aromatic amino acids) was lower than normal and the level of arginine was decreased proportional to the severity of infectionAuthors considered that (1) the amino acid solution specific for starved septic patients should contain lower content of phenylalnine and higher amount of BCAA and arginine as compared with the conventional nutritional amino acid solution; (2) constant elevation of plasma phenylalanine and proline associated with progressive decrease of arginine is one of the meaningful predictive criteria for prognosis of septic patients; (3) inappropriate administration of exogeneous amino acids in metabolic decompensated septic patients might do more harm rather than benefit.