Successful treatment of abdominal compartment syndrome with chemotherapy in a patient with a newly diagnosed Burkitt lymphoma.

Mortality of patients treated on the intensive care unit suffering from cancer is high, especially when admitted with an unknown malignancy. Still, anti-tumor therapy in critically ill patients requiring mechanical ventilation is a clinical challenge. Over the last years, successful chemotherapy has been reported, even in critically ill patients with infections and organ failure. In this report, we present a 42-year old male patient who later was been diagnosed for a highly-malignant lymphoma (Burkitt) developed an abdominal compartment syndrome due to ileus, ascites and progressive intestinal tumor manifestation. During the course, he required mechanical ventilation and developed several organ failures including need for renal replacement therapy. After laparotomy the abdomen was left open and managed by a vacuum dressing. The patient received systemic chemotherapy and broad anti-infective treatment in presence of markedly elevated markers of inflammation. Fortunately, he was successfully weaned from vasopressor and respiratory support. By obtaining negative fluid balances closure of the abdomen succeeded 18 days after laparotomy. The patient was transferred to the normal ward without organ dysfunction on day 27 and discharged home after a second cycle of chemotherapy. In conclusion, aggressive treatment using chemotherapy in critically ill patients with initially unkown malignancy may be successful.

Inhibition of neogenin fosters resolution of inflammation and tissue regeneration.

The resolution of inflammation is an active process that is coordinated by endogenous mediators. Previous studies have demonstrated the immunomodulatory properties of the axonal guidance proteins in the initial phase of acute inflammation. We hypothesized that the neuronal guidance protein neogenin (Neo1) modulates mechanisms of inflammation resolution. In murine peritonitis, Neo1 deficiency (Neo1-/-) resulted in higher efficacies in reducing neutrophil migration into injury sites, increasing neutrophil apoptosis, actuating PMN phagocytosis, and increasing the endogenous biosynthesis of specialized proresolving mediators, such as lipoxin A4, maresin-1, and protectin DX. Neo1 expression was limited to Neo1-expressing Ly6Chi monocytes, and Neo1 deficiency induced monocyte polarization toward an antiinflammatory and proresolving phenotype. Signaling network analysis revealed that Neo1-/- monocytes mediate their immunomodulatory effects specifically by activating the PI3K/AKT pathway and suppressing the TGF-ß pathway. In a cohort of 59 critically ill, intensive care unit (ICU) pediatric patients, we found a strong correlation between Neo1 blood plasma levels and abdominal compartment syndrome, Pediatric Risk of Mortality III (PRISM-III) score, and ICU length of stay and mortality. Together, these findings identify a crucial role for Neo1 in regulating tissue regeneration and resolution of inflammation, and determined Neo1 to be a predictor of morbidity and mortality in critically ill children affected by clinical inflammation.

Intestinal histopathological changes in a porcine model of pneumoperitoneum-induced intra-abdominal hypertension.

BACKGROUND: Low splanchnic perfusion is an immediate effect of pneumoperitoneum-induced intra-abdominal hypertension (IAH). Anatomical structure results in the intestinal mucosa being the area most sensitive to hypoperfusion. The relationship between intestinal injury and clinical parameters of tissue perfusion [abdominal perfusion pressure (APP), gastric intramucosal pH (pHi) and lactic acid (Lc)] has not been previously studied. This study aimed to monitorize intestinal pathogenesis through sequential ileal biopsies and to measure APP, pHi, and Lc levels at different pneumoperitoneum-induced intra-abdominal pressures (20, 30, and 40 mmHg) to evaluate the potential relationships between them. MATERIALS AND METHODS: Fifty pigs were divided into four groups; a control group (C) and three experimental groups with different pneumoperitoneum-induced levels [20 mmHg (G20), 30 mmHg (G30), and 40 mmHg (G40)], that were maintained for 3 and 5 h. APP, pHi, and Lc were measured and ileal biopsies taken laparoscopically every 30 min. The mucosal damage was graded using the standardized Park's Score and animals were classified as injured (I+) or uninjured (I-). RESULTS: Different histopathological lesions were observed in groups G20, G30, and G40 but no damage observed in group C. A 33.3% of animals in G20 and G30 were I+ after 3 h, while 93.3% were injured in G40. After 5 h, histopathological lesions were no longer seen in some animals in G20 and only 10% were I+. Conversely, in G30 I+ pigs increased to 80% while those in G40 remained at 93.3% I+. The I+ animals had significantly lower APP and pHi than those I-. Lc was the clinical parameter that showed the earliest differences, with significantly higher figures in I+ animals. CONCLUSIONS: The evolution of intestinal injuries from pneumoperitoneum-induced IAH depends on the degree of IAP. These damages may be associated with decreases in APP and pHi, and increases in Lc.

[Surgical treatment of chronic pancreatitis complicated by biliary hypertension].

The results of 29 patients treatment, suffering chronic pancreatitis, complicated by biliary hypertension, in whom operative interventions in Department of Surgery of Regional Ivano-Frankivsk clinical hospital in 2009 - 2014 yrs, were analyzed. The drainage, resectional and combined interventions were performed. Direct intervention on pancreatic gland was not applied in 5 (17.2%) patients. Operation to Frey was performed in 7 (24.1%) patients, in 4--it was added by choledochojejunoanastomosis formation, longitudinal pancreatojejunostomy--in 13 (44.8%). In 4 (14.8%) patients while functional disorders of adjacent organs present a pancreaticoduodenal resection to Whipple was done. For biliary hypertension diagnosis (including the occult one) the method of intraoperative pressure measurement in common biliary duct (CBD) was proposed. The operation was added by biliodigestive anastomosis formation, using choledochoenterostomy to Roux method if while operations to Frey or Beger after intervention on pancreatic head with the intrapancreatic CBD freeing the intraductal pressure witnessed the biliary hypertension presence. In all the patients good and satisfactory results of operative treatment were noted.

Intra-abdominal pressure correlates with extracellular water content.

BACKGROUND: Secondary increase in intra-abdominal pressure (IAP) may result from extra-abdominal pathology, such as massive fluid resuscitation, capillary leak or sepsis. All these conditions increase the extravascular water content. The aim of this study was to analyze the relationship between IAP and body water volume. MATERIAL AND METHODS: Adult patients treated for sepsis or septic shock with acute kidney injury (AKI) and patients undergoing elective pharyngolaryngeal or orthopedic surgery were enrolled. IAP was measured in the urinary bladder. Total body water (TBW), extracellular water content (ECW) and volume excess (VE) were measured by whole body bioimpedance. Among critically ill patients, all parameters were analyzed over three consecutive days, and parameters were evaluated perioperatively in surgical patients. RESULTS: One hundred twenty patients were studied. Taken together, the correlations between IAP and VE, TBW, and ECW were measured at 408 time points. In all participants, IAP strongly correlated with ECW and VE. In critically ill patients, IAP correlated with ECW and VE. In surgical patients, IAP correlated with ECW and TBW. IAP strongly correlated with ECW and VE in the mixed population. IAP also correlated with VE in critically ill patients. ROC curve analysis showed that ECW and VE might be discriminative parameters of risk for increased IAP. CONCLUSION: IAP strongly correlates with ECW.

[INTRAABDOMINAL HYPERTENSION AND RESPIRATORY DYSFUNCTION AFTER PLASTY OF THE ABDOMINAL WALL HERNIA].

The impact of intraabdominal pressure on postoperative state of respiratory system after surgery for abdominal wall hernia (AWH) was analyzed. The investigation was conducted in 2013-2014 yrs in 35 patients. Perioperative state of pulmonary mechanics, the gas exchange, and the indices of a spirogram were analyzed. The postoperative period course, the rate of the respiratory insufficiency occurrence were analyzed. Respiratory insufficiency was observed, as a rule, in 24 - 48 h after hernioplasty. The AWH plasty lead to the intraabdominal pressure raising, the PaCO2-EtCO2 gradient changes, and the PaO2/FiO2 ratio as well.

[EXPERIENCE OF RELAPAROTOMY APPLICATION IN SURGICAL TREATMENT OF THE ABDOMINAL CAVITY ORGANS DISEASES].

During 2011 - 2014 yrs in Surgical Clinic of The First City Clinic (Poltava) a relaparotomy was performed in 127 patients. There was established, that relaparotomy constitutes the only one procedure for such life threatening states, as intraabdominal bleeding, ileus in a decompensation stage, eventration, progressing peritonitis, abdominal compartment syndrome stages III - IV. The rate of relaparotomy application after performance of urgent operative interventions is bigger than after planned operations (ratio 4:1). Individual estimation of a state and choice of optimal surgical tactics during primary and secondary operative interventions are needed to improve the results of treatment.

Fulminant Clostridium difficile enteritis causing abdominal compartment syndrome.

INTRODUCTION: Clostridium difficile infection of the small bowel, or C. difficile enteritis (CDE), is an uncommon condition. Cases reported previously have been described in patients with inflammatory bowel disease (IBD), compromised immune systems, or a history of colectomy or small bowel surgery. CASE DESCRIPTION: We present a case of fulminant CDE causing abdominal compartment syndrome following a routine outpatient inguinal hernia repair. This patient developed multiple organ failure dysfunction syndrome requiring surgical abdominal decompression and a small bowel resection. This case highlights the challenges in the diagnosis of CDE, particularly in patients with intact colons and unusual presentations. DISCUSSION: A high index of suspicion is required, as early recognition of CDE is essential in reducing morbidity and mortality. This case report is followed by a review of the current literature on CDE, with a focus on the complexities inherent in the identification of this problem and the decision-making process for surgical intervention.

Hepatopulmonary syndrome: the role of intra-abdominal hypertension and a novel mouse model.

OBJECTIVE: Hepatopulmonary syndrome (HPS) is considered as a triad of chronic liver disease, pulmonary vascular ectasia and severe hypoxemia. The study aims to investigate the pathological mechanism of intra-abdominal pressure (IAP) in HPS and establish a novel mouse model. METHODS: Fifty male ICR mice were randomly divided into experimental and control group, receiving subcutaneous injection of carbon tetrachloride and water, respectively. Mice in experimental group were then divided into 4 sub-groups with the intraperitoneal injection of different volume of albumin to form different IAP (0, 5, 10 and 20 cmH2O). All the mice were then sacrificed 24 hours later and blood gas analysis was conducted. In addition, liver and lung histopathology was also examined. RESULTS: Blood gas analysis in different IAP suggested the respiratory alkalosis. Arterial partial pressure of oxygen significantly decreased in the IAP=10 cmH2O (68.13 ± 3.56, P<0.01) and 20 cmH2O (66.00 ± 3.78, P<0.01). Alveolar-arterial oxygen pressure difference increased markedly in the IAP=10 cmH2O (54.60 ± 6.80, P<0.001) and 20 cmH2O (57.04 ± 5.60, P<0.001). According to lung histopathology, macrophages were found to accumulate in the alveolar spaces and the widened alveolar walls were detected. In addition, there was visible blood stasis in the alveolar walls and numerous red blood cells extravasated into air space in the IAP=10 and 20 cmH2O. CONCLUSIONS: Our study suggested that intra-abdominal hypertension was a significant pathological mechanism of HPS. Meanwhile, we have established a novel mouse model that will now be optimized with further investigation of the mechanism and therapeutic targets of HPS.

Intra-abdominal hypertension in medical critically ill patients: a narrative review.

Intra-abdominal hypertension/abdominal compartment syndrome (IAH/ACS) is a well-recognized entity among surgical subspecialties. Nevertheless, it has been proven to be present in the medical critically ill population. Prospective and retrospective observational studies have found medical patients with IAH/ACS to be associated with death in the intensive care unit and other poor outcomes. Frequently, it is underdiagnosed and undertreated in this patient group. Limitations encountered in these observational studies are their small population size and single-center design. In addition, most studies target consecutive intensive care unit admissions instead of limiting IAH/ACS screening to a predefined population confined by their risk factors (unspecified ascites, mechanical ventilation, positive fluid balance, etc.). Generally, medical patients with IAH/ACS are more severely ill compared with surgical patients. Furthermore, they are less likely to receive treatment targeted at lowering intra-abdominal pressure. Medical treatment of IAH/ACS has not been demonstrated to be specifically effective to avoid decompressive surgery. Identifying medical patients at risk of IAH represents an underresearched area for which training in measurement of abdominal pressure surrogates, awareness of its prevalence, and prevention and treatment of such condition could further improve outcomes in critically ill medical patients.

Intraabdominal hypertention--predisposing factor for visceral alterations and abdominal compartment syndrome.

UNLABELLED: Compartment syndrome (CS) is a condition in which increased pressure in a confined anatomical space adversely affects the function and viability of the tissues therein. AIM: The aim of the following research is to detect the influence of the intraabdominal hypertension (IAH) as an often met condition in visceral surgery on the organs in the abdominal cavity and outside it and on musculus rectus abdominis. METHODS: We used adult Wister rats for creating an experimental model of IAH, using our own experimental method with many advantages. RESULTS: We found expressed alterations in the organs of the group with IAH = 25 mmHg. Morphological changes were found in lung, small intestine, large intestine, stomach, liver, kidneys, spleen and in musculus rectus abdominis In the sham group without IAH we did not find any pathomorphological alterations. CONCLUSIONS. IAH, which is considered as a predictor of ACS and MOF, lasting for only 60 min. and level of = 25 mmHg causes heavy visceral alterations within, and also outside the abdominal cavity, and of the abdominal wall.

[Clinico-morphological substantations of parenchyma-preserving operations performance in surgery of chronic pancreatitis].

There was presented a comparative analysis of the surgical treatment results of 86 patients, suffering chronic pancreatitis, in whom resection and parenchyma-preserving elaborated operations were done, aimed for pancreatic and biliary ducts hypertension elimination. According to histological and histochemical data obtained, there are uniform changes, localized in pancreatic head, corpus and tail: the extended periductal fibrosis with the immune-cell infiltration foci and periductal connective tissue sheath formation. According to the immunohistochemical data obtained, in a fibrous zone there was obtained a big quantity of activated alpha-SMA-positive collagen producing star-like cells and a significant expression of a type IV collagen. Indications for surgical treatment, using parenchyma-preserving procedures, were substantiated, taking into account morphological and clinical data present. The patients quality of life in a late follow-up period (5 years) after performance of a proposed operative procedure (the main group), according to all scales of international questionnaires MOS SF-36 applied, were trustworthy better (P < 0.05), than after resection procedures (control group).

The effects of chronically increased intra-abdominal pressure on the rabbit diaphragm.

BACKGROUND: Diaphragmatic muscular remodeling is caused by various conditions and was mainly studied in pulmonary pathologies and chronic alterations of intra-thoracic pressure. We investigate the effect of the chronically increased intra-abdominal pressure (IAP) on the diaphragm by morphological and biochemical analysis. METHODS: Thirty rabbits were divided into control and study groups. IAP was increased in group B to 12 mmHg for 2 months. The left hemidiaphragm underwent morphological, while the right underwent biochemical analysis. RESULTS: In H&E, all fibers were normal. ATPase analysis demonstrated that type I fibers show no differences between groups. Type ΙΙ(Α) were decreased (p = 0.016) while type ΙΙ(Β/X) fibers were increased (p = 0.025) in group B. Fibers with resistance to fatigue were decreased in group B (p = 0.024). In group B, biochemical activity for glutathione reductase (p = 0.004), glutathione peroxidase (p = 0.021), protein carbonylation (0.029), lipid peroxidation (p = 0.005), and balance of preoxidative-antioxidative factors (p = 0.006) was increased. CONCLUSIONS: Chronically increased IAP induces alterations to the rabbit diaphragm. Adaptation, equivalent to strenuous contraction, transforms the diaphragm to be functionally more efficient toward workload but makes it vulnerable against oxidative stress.

Intracranial hypertension secondary to abdominal compartment syndrome in a girl with giant ovarian cystic mass.

The abdominal compartment syndrome (ACS) is a potentially fatal entity that occurs as a result of an acute increase in intra-abdominal pressure (IAP). The authors report on a girl with a giant ovarian cystic mass, and clinical signs of ACS and intracranial hypertension (ΙΗ). The possible mechanism of IH secondary to ACS is discussed.

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 intra-abdominal pressure (IAP) of the patients were retrospectively evaluated. RESULTS: Eight patients with an initial APACHE IIscore 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.

[Open abdomen management treatment of liver injury in rats with abdominal compartment syndrome and sepsis].

OBJECTIVE: To evaluate the open and closed management treatment of liver injury in rats with sepsis and abdominal compartment syndrome (ACS). METHODS: The sepsis and ACS rats (n = 72) were randomized divided into two groups. One group used closed management (n = 36), the other accepted the open abdomen management (n = 36). The rats were killed at 1, 6 h, 1, 3, 5, 7 d after operation. Blood was collected for liver function tests. Liver sections assessed pathologically and the expressions of Toll-like receptor 4 (TLR4), tumor necrosis factor (TNF)-α, interleukin (IL)-6, signal transducers actuators of transcription (STAT3) and suppressor of cytokine signaling 3 (SOCS3) of rat livers were examined by RT-PCR. RESULTS: The early stage after operation, TNF-α and IL-6 concentrations, STAT3 expressions in rat liver were higher in open abdomen rats than the closed management ones (P < 0.05). TLR4 and SOCS3 expressions were lower in open abdomen rats than the closed management ones (P < 0.05). Aspartate aminotransferase, alanine aminotransferase levels also was lower in open abdomen ones (P < 0.05). CONCLUSIONS: The randomized study demonstrates that open abdomen management could improve liver regeneration in the early stage after operation. Also open abdomen could reduce inflammatory response by reducing TLR4 expressions.

The effect of chronically increased intra-abdominal pressure on rectus abdominis muscle histology an experimental study on rabbits.

BACKGROUND: The aim of this study was to specify the histologic response of the rectus abdominis muscle of the rabbit, to the chronically increased intra-abdominal pressure. MATERIALS AND METHODS: Forty-five New Zealand white rabbits were divided into three groups. In all groups, a rubber bag was implanted into the peritoneal cavity. In group A (n=15) the bags were kept empty. In group B (n=15) the bags were filled with normal saline in order to achieve an intra-abdominal pressure of over 12 mmHg. This pressure was kept at this level for 8 wk. In group C (n=15) the intra-abdominal rubber bags were filled with lead covered by silicone, equiponderant to the mean weight of the normal saline insufflated in group B. After 8 wk we took biopsies of the rectus abdominis muscle and counted the proportion of the different types of muscular fibers (type I, IIA, and IIB/X). RESULTS: Significant difference was found in the proportion of the three types of muscle fibers. Intra-abdominal hypertension led to an increase in type I fibers (P=0.008). No difference was noticed between groups A and C. CONCLUSIONS: The histologic response to the increased intra-abdominal pressure was an increase in type I muscle fibers. Charging with lead did not cause any significant change in the proportion of muscular fibers.