Intestinal ischemia: A rare and less common complication after laparoscopic cholecystectomy-A case report and literature review.

Key Clinical Message: Patients with a history of persistent mesenteric ischemia should not undergo laparoscopy. Mesenteric ischemia must be kept in mind for patients who develop nonspecific abdominal symptoms following laparoscopic surgeries. Abstract: During laparoscopic cholecystectomy (LC), the rise in Intra-Abdominal Pressure due to carbon dioxide insufflation can reduce blood flow through splanchnic vessels, potentially leading to intestinal ischemia. A 72-year-old woman with a history of diabetes, hypertension, ischemic heart disease, and hyperlipidemia underwent LC. She was discharged but readmitted 4 days later due to peritonitis. Ischemic jejunum loops were found during surgery.

Numerical modeling of the abdominal wall biomechanics and experimental analysis for model validation.

The evaluation of the biomechanics of the abdominal wall is particularly important to understand the onset of pathological conditions related to weakening and injury of the abdominal muscles. A better understanding of the biomechanics of the abdominal wall could be a breakthrough in the development of new therapeutic approaches. For this purpose, several studies in the literature propose finite element models of the human abdomen, based on the geometry of the abdominal wall from medical images and on constitutive formulations describing the mechanical behavior of fascial and muscular tissues. The biomechanics of the abdominal wall depends on the passive mechanical properties of fascial and muscle tissue, on the activation of abdominal muscles, and on the variable intra-abdominal pressure. To assess the quantitative contribution of these features to the development and validation of reliable numerical models, experimental data are fundamental. This work presents a review of the state of the art of numerical models developed to investigate abdominal wall biomechanics. Different experimental techniques, which can provide data for model validation, are also presented. These include electromyography, ultrasound imaging, intraabdominal pressure measurements, abdominal surface deformation, and stiffness/compliance measurements.

The Effect of Increased Intra-Abdominal Pressure on Hemodynamics in Laparoscopic Cholecystectomy-The Experience of a Single Centre.

Laparoscopic cholecystectomy is characterized by reduced postoperative pain, shorter hospital stays, rapid return to preoperative physical activity, and less psychological impact on the patient. During laparoscopic cholecystectomy, the intra-abdominal insufflation of carbon dioxide with secondary increase in intra-abdominal pressure can cause important hemodynamic consequences, like decreased cardiac output and blood pressure, as well as compensatory increase in heart rate. The purpose of this study is to evaluate changes in cardiovascular parameters during general anesthesia in patients undergoing laparoscopic cholecystectomy. Retrospective data from 342 patients with cholecystectomy for cholelithiasis performed at Railway Hospital Galati, Romania, were reviewed. All patients received the same intraoperative anesthetics. Female patients were 85.7% (n = 293). More than half of the patients, 53.51% (n = 183), were 40-59 years old, and only 16.37% (n = 56) were under 40 years old. Patients with a normal body mass index (BMI) represented 45.6% (n = 156), 33.3% (n = 114) were underweight, and 12% (n = 42) had grade 1 obesity (BMI 25-29.9 kg/m2). The minimum intraoperative blood pressure correlated with patient gender (p 0.015 < 0.005), with men having a higher blood pressure than women (p 0.006 < 0.05), and for BMI, a higher BMI was associated with elevated blood pressure (p 0.025 < 0.05). Older age correlated with an increased maximum intraoperative blood pressure (p < 0.001 < 0.05) and with maximum intraoperative heart rate (p 0.015 < 0.05). Patients undergoing laparoscopic cholecystectomy experienced significant hemodynamic changes with pneumoperitoneum, but this type of surgical intervention was safe for patients regardless of their age.

Knowledge, attitudes, and practices (KAP) regarding intra-abdominal pressure monitoring among pediatric intensive care nurses: A cross-sectional study.

Objectives: This study aimed to assess the knowledge, attitudes, and practices (KAP) and the training requirements of pediatric intensive care nurses regarding intra-abdominal pressure (IAP) monitoring, in order to provide a reference for the development of relevant training programs and operational procedures in clinical practice. Methods: This descriptive cross-sectional survey was conducted from April 2023 to June 2023. A convenience sample was created by recruiting 212 pediatric intensive care nurses in eight hospitals in Zhejiang Province. A self-developed IAP monitoring KAP assessment tool was used for evaluation, which included knowledge (14 items), attitude (6 items), and practice (8 items), three dimensions, 28 items. Results: The overall KAP score was 60.73 ± 8.35; the knowledge score was 7.84 ± 2.35, with a scoring rate of 56.0%; the attitude score was 25.16 ± 3.23, with a scoring rate of 83.9%; and the practice score was 28.44 ± 6.46, with a scoring rate of 69.3%. Nurses wh-o have received IAP monitoring training have higher KAP score, knowledge score and practice score than those who have not received it (P < 0.05). Nurses aged ≤ 30 showed better knowledge of IAP monitoring than those aged > 30 (P < 0.05). Among the participants, 55.7% of the nurses believed the current knowledge was insufficient to perform IAP measurement effectively. Difficulty in identifying the high-risk population of intra-abdominal hypertension (IAH) (64.6%), unfamiliarity with the operation process of IAP measurement (55.6%), and unreasonable nurse-patient ratio allocation (52.8%) were the main obstacles for nurses to monitor IAP. Conclusions: Pediatric intensive care nurses have a positive attitude towards IAP monitoring, but the knowledge level and practical behavior still need to be strengthened. In particular, the knowledge of published consensus definitions, measurement techniques, and frequency for IAP monitoring is inadequate. It is necessary to implement tailored IAP monitoring training based on their training needs and potential obstacles to promote the standardization and scientificity of IAP monitoring.

Susceptibility of hepato-splanchnic perfusion to intra-abdominal pressure in peritoneal dialysis patients.

BACKGROUND: The impact of peritoneal filling on hepato-splanchnic perfusion during peritoneal dialysis has not been fully elucidated yet. METHODS: Measurements were done in 20 prevalent peritoneal dialysis patients during a peritoneal equilibration test (PET) with 2L of standard dialysate. Data were obtained in the drained state at baseline (T0), after instillation (T1), and after 2 h of dwell time (T2). Intra-abdominal pressure (IAP) was measured by Durand's approach. The hepatic clearance index (KI) of indocyanine-green (ICG) was determined as an indirect measure of hepato-splanchnic blood flow. Cardiac index (CI), heart rate (HR), and total peripheral resistance index (TPRI) were derived from continuous arterial pulse analysis. Fluid volume overload (VO) was evaluated by multifrequency bioimpedance analysis. Ejection fraction (EF) was obtained from echocardiographic examination. RESULTS: IAP was 5.8 ± 3.5 mmHg at baseline (T0), rose to 9.4 ± 2.8 mmHg after instillation of dialysate (T1), and further to 9.7 ± 2.8 mmHg after 2 h of dwell time (p < 0.001). KI slightly declined from 0.60 ± 0.22 L/min/m2 at T0 to 0.53 ± 0.15 L/min/m2 at T1 (p = 0.075), and returned to 0.59 ± 0.22 L/min/m2 at T2 (p = 0.052). CI, HR, and TPRI did not change significantly. In five patients with an EF < 40% KI was significantly lower at T1 (0.42 ± 0.12 L/min/m2; p = 0.039), and further decreased at T2 (0.40 ± 0.04 L/min/m2; p = 0.016) compared to patients with normal EF (T1: 0.58 ± 0.15 L/min/m2 and T2: 0.67 ± 0.22 L/min/m2). CONCLUSIONS: Overall, hepatic clearance of ICG as a marker of hepato-splanchnic blood flow is not affected by the filling of the peritoneal cavity.

An Introduction to Ventra: A Programmable Abdominal Phantom for Training, Educational, Research, and Development Purposes.

BACKGROUND: Intra-abdominal pressure (IAP) is a critical parameter in the care of critically ill patients, as elevated IAP can lead to reduced cardiac output and organ perfusion, potentially resulting in multiple organ dysfunction and failure. The current gold standard for measuring IAP is an indirect technique via the bladder. According to the Abdominal Compartment Society's Guidelines, new measurement methods/devices for IAP must be validated against the gold standard. OBJECTIVES: This study introduces Ventra, an abdominal phantom designed to simulate different IAP levels, abdominal compliance, respiration-related IAP variations, and bladder dynamics. Ventra aims to facilitate the development and validation of new IAP measurement devices while reducing reliance on animal and cadaveric studies. Additionally, it offers potential applications in training and education for biomedical engineering students. This study provides a thorough explanation on the phantom's design and fabrication, which provides a low-cost solution for advancing IAP measurement research and education. The design concept, technical aspects, and a series of validation experiments determining whether Ventra is a suitable tool for future research are presented in this study. METHODS: Ventra's performance was evaluated through a series of validation tests using a pressure gauge and two intra-gastric (Spiegelberg and CiMON) and two intra-bladder (Accuryn and TraumaGuard) pressure measurement devices. The mean and standard deviation of IAP recordings by each device were investigated. Bland-Altman analysis was used to evaluate bias, precision, limits of agreement, and percentage error for each system. Concordance analysis was performed to assess the ability of Ventra in tracking IAP changes. RESULTS: The phantom demonstrated excellent agreement with reference pressure measurements, showing an average bias of 0.11 ± 0.49 mmHg. A concordance coefficient of 100% was observed for the phantom as well. Ventra accurately simulated different abdominal compliances, with higher IAP values resulting in lower compliance. Abdominal volume changes showed a bias of 0.08 ± 0.07 L/min, and bladder fill volume measurements showed an average difference of 0.90 ± 4.33 mL for volumes ranging from 50 to 500 mL. CONCLUSION: The validation results were in agreement with the research guidelines of the world abdominal society. Ventra is a reliable tool that will facilitate the development and validation of new IAP measurement devices. It is an effective educational tool for biomedical engineering students as well.

Effect of Compression Garments on Post-Abdominoplasty Outcomes: A systematic Review of the current Evidence.

Introduction: It is commonly believed that using abdominal binders or compression garments (CGs) after an abdominoplasty could encourage fluid to drain, which would prevent fluid from building up at the surgical site and reduce the risk of seroma and other similar problems. Objective: To evaluate the effect of the use of abdominal binders or CG on the post-operative outcomes following abdominoplasty. Design: Systematic review. Method: Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guidelines were followed to select relevant studies from 2004 to 2024. Data from the included studies were extracted to assess the quality and risk of bias using a modified Jadaad score. Main outcome: Post-operative seroma formation. Secondary outcome: Ventilatory function, intra-abdominal pressure (IAP), and subcutaneous edema were the outcomes of interest. Results: Only 5 trials totaling 130 patients were included in this review. Utilizing post-operative CG following abdominoplasty showed a non-significant tendency to decrease seroma development, ventilatory function, and subcutaneous edema. The limited evidence available also suggested that using post-operative CG increases IAP. Conclusion: Weak evidence supports the beneficial use of abdominal binders following abdominoplasty. Limitations: Low-quality scientific evidence available from the scant data and low caliber of the literature support the use of CG post-abdominoplasty. Therefore, unified outcome reporting and rigid randomized clinical trials are necessary to obtain valid data.

Optimization of kidney function in cardiac surgery patients with intra-abdominal hypertension: expert opinion.

Cardiac surgery-associated acute kidney injury (CSA-AKI) affects up to 42% of cardiac surgery patients. CSA-AKI is multifactorial, with low abdominal perfusion pressure often overlooked. Abdominal perfusion pressure is calculated as mean arterial pressure minus intra-abdominal pressure (IAP). IAH decreases cardiac output and compresses the renal vasculature and renal parenchyma. Recent studies have highlighted the frequent occurrence of IAH in cardiac surgery patients and have linked the role of low perfusion pressure to the occurrence of AKI. This review and expert opinion illustrate current evidence on the pathophysiology, diagnosis, and therapy of IAH and ACS in the context of AKI.

Extracranial pressure (ECP) monitoring in severe traumatic brain injury (TBI): A prospective study validating intra-abdominal pressure (IAP) measurement for predicting intracranial pressure (ICP).

Background: Intracranial pressure (ICP)--guided therapy is the standard of care in the management of severe traumatic brain injury (TBI). Ideal ICP monitoring technique is not yet available, based on its risks associated with bleeding, infection, or its unavailability at major centers. Authors propose that ICP can be gauged based on measuring pressures of other anatomical cavities, for example, the abdominal cavity. Researchers explored the possibility of monitoring intra-abdominal pressure (IAP) to predict ICP in severe TBI patients. Methods: We measured ICP and IAP in severe TBI patients. ICP was measured using standard right frontal external ventricular drain (EVD) insertion and connecting it to the transducer. IAP was measured using a well-established technique of vesical pressure measurement through a manometer. Results: A total of 28 patients (n = 28) with an age range of 18-65 years (mean of 32.36 years ± 13.52 years [Standard deviation]) and the median age of 28.00 years with an interquartile range (21.00-42.00 years) were recruited in this prospective study. About 57.1% (n = 16) of these patients were in the age range of 18-30 years. About 92.9% (n = 26) of the patients were male. The most common mode of injury (78.6%) was road traffic accidents (n = 22) and the mean Glasgow Coma Scale at presentation was 4.04 (range 3-9). The mean ICP measured at the presentation of this patient cohort was 20.04 mmHg. This mean ICP (mmHg) decreased from a maximum of 20.04 at the 0 h' time point (at the time of insertion of EVD) to a minimum of 12.09 at the 96 hr time point. This change in mean ICP (from 0 h to 96 h) was found to be statistically significant (Friedman Test: χ2 = 87.6, P ≤ 0.001). The mean IAP (cmH2O) decreased from a maximum of 16.71 at the 0 h' time point to a minimum of 9.68 at the 96 h' time point. This change was statistically significant (Friedman Test: χ2 = 71.8, P ≤ 0.001). The per unit percentage change in IAP on per unit percentage change in ICP we observed was correlated to each other. The correlation coefficient between these variables varied from 0.71 to 0.89 at different time frames. It followed a trend in a directly proportional manner and was found to be statistically significant (P < 0.001) in each time frame of the study. The rise in one parameter followed the rise in another parameter and vice versa. Conclusion: In this study, we established that the ICP of severe TBI patients correlates well with IAP at presentation. This correlation was strong and constant, irrespective of the timeframe during the treatment and monitoring. This study also established that draining cerebrospinal fluid to decrease ICP in severe TBI patients is reflected in IAP. The study validates that IAP is a strong proxy of ICP in severe TBI patients.

Acute Gastrointestinal Injury in Critically Ill Patients in a South Indian Intensive Care Unit: A Prospective, Observational, Preliminary Study.

Introduction The acute gastrointestinal injury (AGI) score was proposed by the Working Group on Abdominal Problems of the European Society of Intensive Care Medicine (ESICM) as a tool to define and grade gut dysfunction. There have not been any studies in India to validate this tool. The objective of this preliminary study was primarily to study the frequency of AGI in the first week of ICU stay in critically ill patients in our intensive care unit (ICU). We also sought to determine the risk factors predisposing to the development of AGI and to determine the prognostic implication of gastrointestinal (GI) injury in critically ill patients. Materials and methods A prospective, observational, preliminary, single-center study was conducted on critically ill patients (APACHE II > 8) who were on enteral tube feeds and admitted to a mixed ICU of a tertiary care hospital. Anthropometric data, admission diagnosis, APACHE II score, and comorbidities were recorded. Data of daily heart rate, mean arterial pressure, dose of vasopressors, intra-abdominal pressure, fluid balance, feeding intolerance, mechanical ventilation, and laboratory tests were noted for the first seven days of ICU stay or till ICU discharge, whichever was earlier. The occurrence of AGI score (1-4) during the first seven days of critical illness was the primary outcome of interest. Patient outcome at 28 days was recorded and the impact of the occurrence of AGI on patient outcome was analyzed using the Chi-square test. The patient characteristics associated with AGI were characterized as risk factors and analyzed using a multivariate model. Results Data were collected from 33 patients over 201 patient days. The frequency of acute GI dysfunction in the first seven days of ICU stay in our group of patients was 45.45% (15/33). APACHE II, fluid balance, creatinine, and lactate were identified as possible predictors of GI injury based on existing literature. These four variables were entered into an ordinal logistic regression model to assess their ability to predict the occurrence of GI Injury. When fitted into a predictive model, only fluid balance and creatinine were predictive of the final model (p-value < 0.05). A greater fluid balance was predictive in the final model of the development of GI injury; however, it showed negligible clinical significance (OR: 1.00033, 95% CI: 1.000051-1.00061). Lower creatinine levels were predictive in the final model of the development of AGI Injury, as demonstrated by the negative coefficient. Creatinine also had a greater clinical significance (OR: 0.63, 95% CI: 0.44-0.90) in the development of AGI. The impact of the AGI scores on mortality was analyzed. The number of patient days with higher AGI scores was significantly associated with increased mortality at 28 days (p-value < 0.001). Conclusion The study showed that nearly half of the critically ill patients included in the study developed acute GI dysfunction. We could not identify any predictors of GI injury based on our results. The result suggested an association between the severity of GI dysfunction and mortality at 28 days.

Abdominal Congestion as a Predictor of Worsening Renal Function in Patients With Acute Decompensated Heart Failure.

Background: Worsening renal function is a frequent finding in patients with acute decompensated heart failure (ADHF) and is a powerful independent prognostic factor for adverse outcomes. The link between abdominal congestion and worsening renal function in such patients is not yet fully addressed. Objective: To evaluate the role of abdominal congestion in the early prediction of worsening renal function in hospitalized patients with acute decompensated heart failure. Methods: This was a prospective study that enrolled 100 patients with a diagnosis of ADHF and received intravenous diuretic therapy. Intra-abdominal pressure (IAP), splenic Doppler impedance indices and serum prouroguanylin were measured on admission, 24 h after admission and on discharge. Patients were then divided into 2 groups: those who developed WRF (WRF group), and those who did not (non-WRF group). Worsening renal function was defined as an increase in serum creatinine level ≥0.3 mg/dL above baseline admission value. Intrabdominal pressure was measured transvesically using standard Foley catheter. Splenic Doppler impedance indices (resistivity and pulsatility indices) were measured using splenic Doppler ultrasound. Results: Among recruited patients (age: 54.73 ± 13.1 years, 72% are male), there was a significant decline in IAP (6.67 mmHg vs 8.36 mmHg, p = 0.001) and significant rise in splenic resistivity index (0.69 vs 0.67, p = 0.002) before discharge compared to admission values. The median level of serum prouroguanylin before discharge showed significant decline compared to admission level (29.2 vs 34.6 ng/l, p = 0.006). WRF developed in 37 (37%) patients. Independent predictors of WRF during hospitalization were high splenic arterial resistivity index 24 h after admission, high intra-abdominal pressure (≥8 mmHg) 24 h after admission, and low LVEF on admission. Conclusion: In ADHF patients receiving diuretic therapy, transvesical measurement of intra-abdominal pressure and splenic resistivity index by splenic Doppler early after admission can help to identify patients at increased risk of WRF near discharge.

An Analysis of the Impact of Intra-abdominal Pressure on Surgical Outcomes in Cases of Intestinal Obstruction: A Prospective Observational Study.

BACKGROUND: The decision and timing of surgical exploration of intestinal obstruction depend on the clinical findings and probable etiology of the symptoms. Patients with intestinal obstruction often have intra-abdominal hypertension (IAH), which is associated with a poor prognosis. PURPOSE OF THE STUDY: The purpose of the study is to evaluate the surgical outcomes in patients with intestinal obstruction in relation to intra-abdominal pressure (IAP). MATERIALS AND METHODS: The study was conducted on 50 patients with intestinal obstruction undergoing surgery. Preoperatively, IAP was measured in all the patients and was allocated into two groups based on the presence or absence of IAP. Patients were assessed for the postoperative length of hospital or ICU stay, surgical site infection, wound dehiscence, and recovery following surgery. RESULTS: The patients with preoperative IAH had significantly longer postoperative stays, with a median stay of eight days in these patients compared to four days in patients without IAH (p=0.009). A significantly higher number of patients (24%) had gangrenous changes on the bowel wall (p=0.042) and fascial dehiscence (p=0.018) in the group associated with raised IAP. A total of 75% of patients who required ventilator support belonged to the raised IAP group. The mean IAP in patients admitted to the ICU was significantly higher than in patients not admitted to the ICU (p=0.027). CONCLUSION: Preoperative IAH in intestinal obstruction is a significant factor in predicting the possibility of bowel ischemia with gangrene, perforation, intra-abdominal sepsis, surgical site infections, and prolonged hospital stay. Early surgical exploration and abdominal decompression must be considered in such cases.

Abdominocentesis and intra-abdominal pressure measurement in small animals.

OBJECTIVE: To provide a video tutorial detailing how to perform "blind" and ultrasound-guided abdominocentesis for diagnostic and therapeutic guidance, and to provide a brief demonstration of intra-abdominal pressure measurement (IAP). ANIMALS: Any cat or dog with suspicion of free abdominal effusion or patients requiring measurement of IAP. METHODS: Abdominocentesis should be performed when there is high suspicion for peritoneal effusion based on physical exam and/or diagnostic imaging. The 4-quadrant tap uses 20-gauge or larger needles placed blindly in ≥ 1 of the 4 quadrants of the abdomen to collect abdominal fluid. In contrast, ultrasound allows visualization of fluid in the abdomen prior to percutaneous insertion of a needle and syringe to collect fluid. Regardless of collection technique, fluid should have immediate cytologic analysis and later can be submitted for biochemical parameters, additional cellular analysis by a pathologist, and culture and sensitivity (in rare cases if indicated). Intravesicular bladder pressure measurement using a manometer-urinary catheter system approximates the IAP when there is concern for organ hypoperfusion and compartment syndrome. RESULTS: Abdominocentesis can be performed with and without the use of ultrasound guidance. Intravesicular bladder pressure measurement is used to diagnose and trend IAP values before and after treatments are performed. CLINICAL RELEVANCE: Abdominocentesis is a simple and safe technique that all small animal clinicians should be comfortable performing. Effusion sampling can guide further diagnostics and treatments. Measurement of IAP is simple and requires no specialized equipment.

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.

Intra-abdominal hypertension and compartment syndrome after complex hernia repair.

PURPOSE: Abdominal compartment syndrome (ACS) is a well-known concept after trauma surgery or after major abdominal surgery in critically ill patients. However, ACS as a complication after complex hernia repair is considered rare and supporting literature is scarce. As complexity in abdominal wall repair increases, with the introduction of new tools and advanced techniques, ACS incidence might rise and should be carefully considered when dealing with complex abdominal wall hernias. In this narrative review, a summary of the current literature will highlight several key features in the diagnosis and management of ACS in complex abdominal wall repair and discuss several treatment options during the different steps of complex AWR. METHODS: We performed a literature search across PubMed using the search terms: "Abdominal Compartment syndrome," "Intra-abdominal pressure," "Complex abdominal hernia," and "Ventral hernia." Articles corresponding to these search terms were individually reviewed by primary author and selected on relevance. CONCLUSION: Intra-abdominal hypertension (IAH) and ACS require imperative attention and should be carefully considered when dealing with complex abdominal wall hernias, even without significant loss of domain. Development of a true abdominal compartment syndrome is relatively rare, but is a devastating complication and should be prevented at all cost. Current evidence on surgical treatment of ACS after hernia repair is scarce, but conservative management might be an option in the early phase and low grades of IAH. However, life-saving treatment by relaparotomy and open abdomen management should be initiated when ACS starts setting in.

[Abdominal compartment syndrome in visceral surgery and intensive care medicine : Causes, prevention, detection, treatment]. / Abdominelles Kompartmentsyndrom in der Viszeralchirurgie und Intensivmedizin : Ursachen, Prävention, Erkennung, Therapie.

An increased intra-abdominal pressure can result in a manifest abdominal compartment syndrome (ACS) with significant organ damage, which is a life-threatening situation associated with a high mortality. Although the etiology is manifold and critically ill patients on the intensive care unit are particularly endangered, the disease is often not diagnosed even though the measurement of bladder pressure is available as a simple and standardized method; however, particularly the early detection of an increased intra-abdominal pressure is decisive in order to prevent the occurrence of a manifest ACS with (multi)organ failure by means of conservative measures. In cases of a conservative refractory situation, decompressive laparotomy is indicated.

An estimation of the biomechanical properties of the continent and incontinent woman bladder via inverse finite element analysis.

Stress urinary incontinence often results from pelvic support structures' weakening or damage. This dysfunction is related to direct injury of the pelvic organ's muscular, ligamentous or connective tissue structures due to aging, vaginal delivery or increase of the intra-abdominal pressure, for example, defecation or due to obesity. Mechanical changes alter the soft tissues' microstructural composition and therefore may affect their biomechanical properties. This study focuses on adapting an inverse finite element analysis to estimate the in vivo bladder's biomechanical properties of two groups of women (continent group (G1) and incontinent group (G2)). These properties were estimated based on MRI, by comparing measurement of the bladder neck's displacements during dynamic MRI acquired in Valsalva maneuver with the results from inverse analysis. For G2, the intra-abdominal pressure was adjusted after applying a 95% impairment to the supporting structures. The material parameters were estimated for the two groups using the Ogden hyperelastic constitutive model. Finite element analysis results showed that the bladder tissue of women with stress urinary incontinence have the highest stiffness (α1 = 0.202 MPa and µ1 = 7.720 MPa) approximately 47% higher when compared to continent women. According to the bladder neck's supero-inferior displacement measured in the MRI, the intra-abdominal pressure values were adjusted for the G2, presenting a difference of 20% (4.0 kPa for G1 and 5.0 kPa for G2). The knowledge of the pelvic structures' biomechanical properties, through this non-invasive methodology, can be crucial in the choice of the synthetic mesh to treat dysfunction when considering personalized options.

Adjuvant Botulinum Toxin Type A on the Management of Giant Hiatal Hernia: A Case Report.

The management of giant hiatal hernias (HHs) remains challenging and is associated with a high risk of recurrence. Currently, several strategies are used to reduce recurrence, and a newly proposed trend is the administration of adjuvant botulinum toxin type A (BTX), a procedure already performed in complex ventral hernias. Here, we present a case of a 63-year-old man with a giant paraesophageal HH type IV containing the entire stomach and transverse colon with loss of domain, who underwent adjuvant BTX and subsequently laparoscopic hiatoplasty with a biological mesh with partial fundoplication. At six months' follow-up, the patient reported a significant improvement in the quality of life without dysphagia or gastroesophageal reflux and with a good respiratory function. A control computed tomography was performed, which documented a partial recurrence of HH, completely asymptomatic. This clinical case showed the successful treatment of a giant HH using adjuvant BTX injection to increase abdominal wall compliance as had already been described in the treatment of complex ventral hernia. Thus, the use of BTX is a promising strategy for selected cases of giant HHs mainly if there is a loss of domain; however, more case series and controlled trials are needed to show the reproducibility of the benefit of this strategy.

Intra-abdominal Pressure Measurement as a Predictor of Postoperative Wound Complications in Patients Undergoing Emergency Laparotomy: A Prospective Observational Study.

Introduction Elevated intra-abdominal pressure (IAP) hampers the effective functioning of intra- and extra-abdominal organs. Despite the abundance of knowledge, routine measurement of IAP still needs to be widely incorporated in managing at-risk patients. The present study intends to assess the need for IAP measurement on abdominal wound healing in emergency laparotomy patients. Methods This prospective study was carried out over 24 months in patients undergoing emergency laparotomy. The IAP was measured at admission, immediately after surgery, and during the early postoperative period at 6, 12, 24, 48, and 72 hours. The patients were evaluated for the development of wound-related complications over a follow-up period of three months post-operatively. Results Seventy-two patients were enrolled. At admission, 54 (75%) patients had intra-abdominal hypertension (IAH), of which three patients had evidence of abdominal compartment syndrome. Thirty-one (43%) patients developed postoperative wound infections. The overall incidence of wound infection was significantly higher in patients with IAH (54.3% vs. 24%, p-value = 0.04, Pearson's Chi-squared test). The frequency of wound dehiscence was greater (19.6 % vs. 4.3 %, p-value 0.14, Fischer's exact test) in patients with IAH. The median duration of hospital stay (13 vs. 8 days, p-value 0.02, Mann-Whitney U test) and healing time (30.5 vs. 18 days, p-value 0.02, Mann-Whitney U test) was significantly higher in patients with IAH. Conclusion Measurement of IAP is a relatively simple procedure that should be incorporated into the routine postoperative care of surgical patients. The presence of elevated IAP can identify the subset of patients at risk of increased postoperative wound complications.

Prevalence of increased intra-abdominal pressure and its impact on renal function in acute decompensated heart failure: A prospective pilot study.

BACKGROUND: Intra-abdominal pressure (IAP) is a frequently overlooked aspect in clinical assessment that can have a significant impact on organ dysfunction in patients with acute decompensated heart failure (ADHF). AIMS: We aimed to investigate dynamics of IAP in patients with ADHF and its impact on diuretic response. METHODS: We conducted a prospective observational pilot study on a group consisting of 30 patients admitted for ADHF. In every individual IAP measurement, blood and urine samples were taken upon admission, on the second and third days of hospitalization. RESULTS: The study showed a high (63.3%) prevalence of intra-abdominal hypertension (IAH) defined as IAP ≥12 mm Hg upon admission, while only roughly 13% had signs of ascites. We observed poorer diuresis on the first day of hospitalization in the IAH group (P = 0.03). IAP was negatively correlated with urine output (P = 0.01) and positively correlated with urine osmolality (P = 0.03) on the first day of hospitalization. During follow-up, there was a significant decrease in IAP in patients with IAH upon admission who received standard decongestive therapy. CONCLUSIONS: The study shows a high prevalence of IAH in patients admitted for ADHF, even in individuals who do not present symptoms of abdominal congestion. Established correlation between IAP, reduced diuresis, and increased urine osmolality, despite achieving target natriuresis, contributes novel insights into the understanding of pathomechanisms underlying diuretic resistance in ADHF.