Incidence, diagnosis, management and outcome of acute mesenteric ischaemia: a prospective, multicentre observational study (AMESI Study).

BACKGROUND: The aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI). METHODS: All adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected. RESULTS: AMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied. CONCLUSIONS: The overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management. TRIAL REGISTRATION: NCT05218863 (registered 19.01.2022).

Fluid Management, Intra-Abdominal Hypertension and the Abdominal Compartment Syndrome: A Narrative Review.

BACKGROUND: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. OBJECTIVES: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). METHODS: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. RESULTS: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. CONCLUSIONS: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.

Food Intake Following Gastric Bypass Surgery: Patients Eat Less but Do Not Eat Differently.

BACKGROUND: Lack of robust research methodology for assessing ingestive behavior has impeded clarification of the mediators of food intake following gastric bypass (GBP) surgery. OBJECTIVES: To evaluate changes in directly measured 24-h energy intake (EI), energy density (ED) (primary outcomes), eating patterns, and food preferences (secondary outcomes) in patients and time-matched weight-stable comparator participants. METHODS: Patients [n = 31, 77% female, BMI (in kg/m2) 45.5 ± 1.3] and comparators (n = 32, 47% female, BMI 27.2 ± 0.8) were assessed for 36 h under fully residential conditions at baseline (1 mo presurgery) and at 3 and 12 mo postsurgery. Participants had ad libitum access to a personalized menu (n = 54 foods) based on a 6-macronutrient mix paradigm. Food preferences were assessed by the Leeds Food Preference Questionnaire. Body composition was measured by whole-body DXA. RESULTS: In the comparator group, there was an increase in relative fat intake at 3 mo postsurgery; otherwise, no changes were observed in food intake or body composition. At 12 mo postsurgery, patients lost 27.7 ± 1.6% of initial body weight (P < 0.001). The decline in EI at 3 mo postsurgery (-44% from baseline, P < 0.001) was followed by a partial rebound at 12 mo (-18% from baseline), but at both times, dietary ED and relative macronutrient intake remained constant. The decline in EI was due to eating the same foods as consumed presurgery and by decreasing the size (g, MJ), but not the number, of eating occasions. In patients, reduction in explicit liking at 3 mo (-11.56 ± 4.67, P = 0.007) and implicit wanting at 3 (-15.75 ± 7.76, P = 0.01) and 12 mo (-15.18 ± 6.52, P = 0.022) for sweet foods were not matched by reduced intake of these foods. Patients with the greatest reduction in ED postsurgery reduced both EI and preference for sweet foods. CONCLUSIONS: After GBP, patients continue to eat the same foods but in smaller amounts. These findings challenge prevailing views about the dynamics of food intake following GBP surgery. This trial was registered as clinicaltrials.gov as NCT03113305.

A Comparison of Total Food Intake at a Personalised Buffet in People with Obesity, before and 24 Months after Roux-en-Y-Gastric Bypass Surgery.

Long-term reductions in the quantity of food consumed, and a shift in intake away from energy dense foods have both been implicated in the potent bariatric effects of Roux-en-Y gastric bypass (RYGB) surgery. We hypothesised that relative to pre-operative assessment, a stereotypical shift to lower intake would be observed at a personalised ad libitum buffet meal 24 months after RYGB, driven in part by decreased selection of high energy density items. At pre-operative baseline, participants (n = 14) rated their preference for 72 individual food items, each of these mapping to one of six categories encompassing high and low-fat choices in combination with sugar, complex carbohydrate or and protein. An 18-item buffet meal was created for each participant based on expressed preferences. Overall energy intake was reduced on average by 60% at the 24-month buffet meal. Reductions in intake were seen across all six food categories. Decreases in the overall intake of all individual macronutrient groups were marked and were generally proportional to reductions in total caloric intake. Patterns of preference and intake, both at baseline and at follow-up appear more idiosyncratic than has been previously suggested by verbal reporting. The data emphasise the consistency with which reductions in ad libitum food intake occur as a sequel of RYGB, this being maintained in the setting of a self-selected ad libitum buffet meal. Exploratory analysis of the data also supports prior reports of a possible relative increase in the proportional intake of protein after RYGB.

An Exploration of the Patient Lived Experience of Remission and Relapse of Type 2 Diabetes Following Bariatric Surgery.

BACKGROUND: Bariatric surgery is the most effective treatment for patients with obesity and type 2 diabetes (T2DM), inducing profound metabolic changes associated with improvements in glycaemic control. In spite of the recognition of the physiological changes associated with bariatric surgery, what remains underappreciated is the patient experience of surgery to treat T2DM. OBJECTIVES: This study explored the patient experience with regard to motivations, expectations and outcomes, including remission and relapse of diabetes. METHODS: An in-depth qualitative approach was adopted, encompassing semi-structured interviews with patients (n=17) living with obesity and T2DM both pre- and postsurgery. Interpretive thematic analysis identified emergent themes using a grounded approach. RESULTS: Analysis revealed a number of themes throughout the interviews which included motivations and perceived benefits of surgery, obesity stigma and its impact on self-worth as well as perceptions of remission or relapse and the implications for sense of control. CONCLUSIONS: The motivation for undergoing bariatric surgery was driven by health concerns, namely T2DM and the desire to reduce the risk of developing diabetes-related complications. Patients highlighted social and self-stigmatisation associated with obesity and T2DM, leading to feelings of shame and an inability to seek support from family or healthcare professionals. Stigmatisation created a sense of failure and feeling of guilt for having T2DM. As a result, patients felt responsible for maintaining disease remission postoperatively and regarded the need for medication as a sign of treatment failure.

Intra-abdominal hypertension and hypoxic respiratory failure together predict adverse outcome - A sub-analysis of a prospective cohort.

PURPOSE: To assess whether the combination of intra-abdominal hypertension (IAH, intra-abdominal pressure ≥ 12 mmHg) and hypoxic respiratory failure (HRF, PaO2/FiO2 ratio < 300 mmHg) in patients receiving invasive ventilation is an independent risk factor for 90- and 28-day mortality as well as ICU- and ventilation-free days. METHODS: Mechanically ventilated patients who had blood gas analyses performed and intra-abdominal pressure measured, were included from a prospective cohort. Subgroups were defined by the absence (Group 1) or the presence of either IAH (Group 2) or HRF (Group 3) or both (Group 4). Mixed-effects regression analysis was performed. RESULTS: Ninety-day mortality increased from 16% (Group 1, n = 50) to 30% (Group 2, n = 20) and 27% (Group 3, n = 100) to 49% (Group 4, n = 142), log-rank test p < 0.001. The combination of IAH and HRF was associated with increased 90- and 28-day mortality as well as with fewer ICU- and ventilation-free days. The association with 90-day mortality was no longer present after adjustment for independent variables. However, the association with 28-day mortality, ICU- and ventilation-free days persisted after adjusting for independent variables. CONCLUSIONS: In our sub-analysis, the combination of IAH and HRF was not independently associated with 90-day mortality but independently increased the odds of 28-day mortality, and reduced the number of ICU- and ventilation-free days.

Systematic Review and Meta-Analysis of Wound Bundles in Emergency Midline Laparotomy Identifies That It Is Time for Improvement.

BACKGROUND: Emergency midline laparotomy is the cornerstone of survival in patients with peritonitis. While bundling of care elements has been shown to optimize outcomes, this has focused on elective rather than emergency abdominal surgery. The aim of this study was to undertake a systematic review and meta-analysis of factors affecting the development of surgical site infection (SSI) in patients undergoing midline emergency laparotomy. METHODS: An ethically approved, PROSPERO registered (ID: CRD42020193246) meta-analysis and systematic review, searching PubMed, Scopus, Web of Science and Cochrane Library electronic databases from January 2015 to June 2020 and adhering to PRISMA guidelines was undertaken. Search headings included "emergency surgery", "laparotomy", "surgical site infection", "midline incision" and "wound bundle". Suitable publications were graded using Methodological Index for Non-Randomised Studies (MINORS); papers scoring ≥16/24 were included for data analysis. The primary outcome in this study was SSI rates following the use of wound bundles. Secondary outcomes consisted of the effect of the individual interventions included in the bundles and the SSI rates for superficial and deep infections. Five studies focusing on closure techniques were grouped to assess their effect on SSI. RESULTS: This study identified 1875 articles. A total of 58 were potentially suitable, and 11 were included after applying MINORS score. The final cohort included 2,856 patients from eight countries. Three papers came from the USA, two papers from Japan and the remainder from Denmark, England, Iran, Netherlands, Spain and Turkey. There was a 32% non-significant SSI reduction after the implementation of wound bundles (RR = 0.68; CI, 0.39-1.17; p = 0.16). In bundles used for technical closure the reduction in SSI of 15% was non-significant (RR = 0.85; CI, 0.57-1.26; p = 0.41). Analysis of an effective wound bundle was limited due to insufficient data. CONCLUSIONS: This study identified a significant deficit in the world literature relating to emergency laparotomy and wound outcome optimisation. Given the global burden of emergency general surgery urgent action is needed to assess bundle's ability to potentially improve outcome after emergency laparotomy.

Polycompartment syndrome - intra-abdominal pressure measurement.

Intra-abdominal hypertension and the abdominal compartment syndrome are well-known, serious, life-threatening clinical entities in acute care surgery. A common characteristic of these syndromes is the permanent and irreversible damage that may affect the organs which can be found inside the given compartment if quick intervention cannot be provided. All factors which may and can lead to a sudden increase in the intra-abdominal pressure can be found among the triggering factors of abdominal compartment syndrome. Despite the modern and quick diagnostics, and the adequate surgical interventions performed in time, the mortality of this syndrome is extremely high (38-71%). It affects practically all vital organ systems: cardiovascular, respiratory, urinary and central nervous system. There are four major compartments in the human body: the head, the chest, the abdomen and the extremities. When two or more compartments have elevated pressures the name of the clinical entity is polycompartment syndrome, first described in 2007. The only possible way of establishing the diagnosis is to measure the intra-abdominal pressure, a widespread manner of which is the measurement through the bladder. Treatment of abdominal and polycompartment syndrome is nearly always surgical decompression with temporary abdominal wall closure or open abdominal treatment. Clinicians need to be aware of the real existence of polycompartment syndrome and the complex and constant interplay of raised pressure between compartments. This highlights the importance of research and development of new intra-abdominal pressure measurement techniques.

Pressure Distribution during Negative Pressure Wound Therapy of Experimental Abdominal Compartment Syndrome in a Porcine Model.

(1) Introduction: Negative pressure wound therapy (NPWT) is a frequently applied open abdomen (OA) treatment. There are only a few experimental data supporting this method and describing the optimal settings and pressure distribution in the abdominal cavity during this procedure. The aim of our study was to evaluate pressure values at different points in the abdominal cavity during NPWT in experimental abdominal compartment syndrome (ACS) animal model; (2) Methods: In this study (permission Nr. 13/2014/UDCAW), 27 Hungahib pigs (15.4-20.2 kg) were operated on. ACS was generated by implanting a plastic bag in the abdomen through mini-laparotomy and filled with 2100-3300 mL saline solution (37 °C) to an intraabdominal pressure (IAP) of 30 mmHg. After 3 h, NPWT (Vivano Med® Abdominal Kit, Paul Hartmann AG, Germany) or a Bogota bag was applied. The NPWT group was divided into -50, -100 and -150 mmHg suction groups. Pressure distribution to the abdominal cavity was monitored at 6 different points of the abdomen via a multichannel pressure monitoring system; (3) Results: The absolute pressure levels were significantly higher above than below the protective layer. The values of the pressure were similar in the midline and laterally. Amongst the bowels, the pressure values changed periodically between 0 and -12 mmHg which might be caused by peristaltic movements; (4) Conclusions: The porcine model of the present study seems to be well applicable for investigating ACS and NPWT. It was possible to provide valuable information for clinicians. The pressure was well distributed by the protective layer to the lateral parts of the abdomen and this phenomenon did not change considerably during the therapy.

Laparoscopic management of a complicated case of Wilkie's syndrome: A case report.

INTRODUCTION: Superior mesenteric artery (SMA) syndrome also known as Wilkie's syndrome is a rare condition caused by the entrapment of the third part of the duodenum between the aorta and the SMA. The incidence of Wilkie's syndrome range between 0.013% and 0.3%. The normal angle between the aorta and SMA has been described to range between 38° and 65°, whereas in Wilkie's syndrome this angle is reduced to less than 20° causing gastric outlet obstruction. CASE PRESENTATION: We report a case of a previously diagnosed 43 year-old male with SMA syndrome, whom had been conservatively managed for 5-years for recurrent admissions with symptoms of gastric outlet obstruction. During his last admission, CT abdomen demonstrated gastric pneumatosis and portal venous gas requiring urgent surgical intervention. Duodenojejunostomy was successfully performed using laparoscopic technique. DISCUSSION: SMA syndrome is thought to occur secondary to the rapid and excessive weight loss leading to the reduction of the mesenteric fat around the aorta and SMA, thereby reducing the normal angle between the two arteries. Conservative medical management is usually the first line of treatment in uncomplicated cases. Surgical management is usually reserved only after failed conservative management or complicated cases, at which time either an open or laparoscopic surgical approach is undertaking. CONCLUSION: Surgical intervention is the mainstay in complicated cases of SMA syndrome and in refractory cases to conservative management. Advantages of laparoscopic approach over open surgery include rapid recovery time, reduced post-operative pain and shorter hospital stay.

[Ten years' experience in the research of abdominal compartment syndrome (2004-2014)]. / Tíz év tapasztalata a hasi kompartmentszindróma kutatásában (2004-2014).

Intra-abdominal hypertension and abdominal compartment syndrome are frequent findings among severe surgical ill patients. In spite of the fast diagnostic methods and effective therapeutic procedures the mortality is high. The causing factors lead to increased intra-abdominal pressure and abdominal compartment syndrome. It can be defined as adverse physiologic consequences that occur as a result of an acute increase in the intra-abdominal pressure. The most common causes are retroperitoneal haemorrhage, pancreatitis, bowel obstruction, tense ascites, peritonitis and serious visceral edema due to massive fluid resuscitation. The affected systems are cardiovascular, respiratory, renal, central nervous systems, splanchnic organs, and finally the whole body. The diagnostic method is the intra-abdominal pressure monitoring. The bases of the treatment are adequate fluid resuscitation, non-surgical management and decompression. The authors review the topic including the international and Hungarian references based on their ten years experience.

Does femoral venous pressure measurement correlate well with intrabladder pressure measurement? A multicenter observational trial.

PURPOSE: To investigate if femoral venous pressure (FVP) measurement can be used as a surrogate measure for intra-abdominal pressure (IAP) via the bladder. METHODS: This was a prospective, multicenter observational study. IAP and FVP were simultaneously measured in 149 patients. The effect of BMI on IAP was investigated. RESULTS: The incidences of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) were 58 and 7% respectively. The mean APACHE II score was 22 ± 10, SAPS 2 score 42 ± 20, and SOFA score 9 ± 4. The mean IAP was 11.2 ± 4.5 mmHg versus 12.7 ± 4.7 mmHg for FVP. The bias and precision for all measurements were -1.5 and 3.6 mmHg respectively with the lower and upper limits of agreement being -8.6 and 5.7. When IAP was above 20 mmHg, the bias between IAP and FVP was 0.7 with a precision of 2.0 mmHg (lower and upper limits of agreement -3 and 4.6 respectively). Excluding those with ACS, according to the receiver operating curve analysis FVP = 11.5 mmHg predicted IAH with a sensitivity and specificity of 84.8 and 67.0% (AUC of 0.83 (95% CI 0.81-0.86) with P < 0.001). FVP = 14.5 mmHg predicted IAP above 20 mmHg with a sensitivity of 91.3% and specificity of 68.1% (AUC 0.85 (95% CI 0.79-0.91), P < 0.001). Finally, at study entry, the mean IAP in patients with a BMI less then 30 kg/m(2) was 10.6 ± 4.0 mmHg versus 13.8 ± 3.8 mmHg in patients with a BMI ≥ 30 kg/m(2) (P < 0.001). CONCLUSIONS: FVP cannot be used as a surrogate measure of IAP unless IAP is above 20 mmHg.

Beneficial effects of theophylline infusions in surgical patients with intra-abdominal hypertension.

BACKGROUND: Intra-abdominal hypertension (IAH) can cause high mortality. Recently, we found that IAH was associated with increased serum levels of adenosine and interleukin 10. Our present "hypothesis-generated study" was based on the above mentioned results. MATERIALS AND METHODS: In this uncontrolled clinical trial, a total of 78 patients with IAH were enrolled representing a 13-20 mmHg range of intra-abdominal pressure (IAP). Patients requiring surgical abdominal decompression were excluded. Patients were treated with the following protocols: standard supportive therapy (ST, n = 38) or ST plus infusion with the adenosine receptor antagonist theophylline (T, n = 40). Over the 5-day measurement period, IAP was monitored continuously and serum adenosine concentration and other clinical and laboratory measurements were monitored daily. Mortality was followed for the first 30 days following the diagnosis of IAH. RESULTS: Mortality of ST patients was 55%, which is compatible to other studies. Serum adenosine concentration was found to be directly proportional to IAP. Of the 40 patients receiving T treatment, survival was 100%. An increased survival related to theophylline infusion correlated with improving serum concentrations of IL-10, urea, and creatinine, as well as 24-h urine output, fluid balance, mean arterial pressure, and O(2)Sat. CONCLUSIONS: Adenosine receptor antagonism with T following IAH diagnosis resulted in markedly reduced mortality in patients with moderated IAH (<20 mmHg). Theophylline-associated mortality reduction may be related to improved renal perfusion and improved MAP, presumably caused by adenosine receptor blockade. Because this study was not a randomized controlled study, these compelling observations require further multicentric clinical confirmation.

Increased serum adenosine and interleukin 10 levels as new laboratory markers of increased intra-abdominal pressure.

BACKGROUND: Increased intra-abdominal pressure (IAP), intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are severe complications of surgical interventions with a high rate of mortality. The technique of IAP measurement is accurate, precise, reproducible and cost-effective. However, laboratory measures for monitoring of IAH have not been defined. We investigated the linkage between the serum levels of adenosine and interleukin 10 (IL-10) with IAP. METHODS: The sera of 25 surgical patients with IAP <12 mmHg and of 45 surgical patients with IAP >12 mmHg were tested. Serum adenosine concentration was measured by HPLC. Serum IL-1ß, IL-2, IL-4, IL-10, TNFα, IFNγ and IL-10 were determined by enzyme linked immunosorbent assay (ELISA). CRP was measured by nephelometry. RESULTS: Significant correlations of IAP were found only with serum levels of adenosine and IL-10. In the sera of patients with IAP >12 mmHg, the levels of both adenosine (1.61 versus 0.06 µM, p < 0.01) and IL-10 (63.23 versus 27.27 pg/ml, p < 0.01) were significantly higher than those in patients with IAP <12 mmHg. Moreover, significant correlations were found between individual patient IAP-adenosine values (r = 0.766, p < 0.001), IAP-IL-10 values (r = 0.792, p < 0.001) and adenosine-IL-10 values (r = 0.888, p < 0.001). A direct linear correlation between IAP-adenosine and IAP-10 values was only observed with IAP >15 (Grade II-IV). CONCLUSION: We report associations between IAP and the serum adenosine and IL-10 levels providing new tools for the laboratory monitoring of IAH as well as further understanding of the pathomechanisms contributing to ACS.

The impact of body position on intra-abdominal pressure measurement: a multicenter analysis.

OBJECTIVE: Elevated intra-abdominal pressure (IAP) is a frequent cause of morbidity and mortality among the critically ill. IAP is most commonly measured using the intravesicular or "bladder" technique. The impact of changes in body position on the accuracy of IAP measurements, such as head of bed elevation to reduce the risk of ventilator-associated pneumonia, remains unclear. DESIGN: Prospective, cohort study. SETTING: Twelve international intensive care units. PATIENTS: One hundred thirty-two critically ill medical and surgical patients at risk for intra-abdominal hypertension and abdominal compartment syndrome. INTERVENTIONS: Triplicate intravesicular pressure measurements were performed at least 4 hours apart with the patient in the supine, 15 degrees , and 30 degrees head of bed elevated positions. The zero reference point was the mid-axillary line at the iliac crest. MEASUREMENTS AND MAIN RESULTS: Mean IAP values at each head of bed position were significantly different (p < 0.0001). The bias between IAPsupine and IAP15 degrees was 1.5 mm Hg (1.3-1.7). The bias between IAPsupine and IAP30 degrees was 3.7 mm Hg (3.4-4.0). CONCLUSIONS: Head of bed elevation results in clinically significant increases in measured IAP. Consistent body positioning from one IAP measurement to the next is necessary to allow consistent trending of IAP for accurate clinical decision making. Studies that involve IAP measurements should describe the patient's body position so that these values may be properly interpreted.

The effect of different reference transducer positions on intra-abdominal pressure measurement: a multicenter analysis.

OBJECTIVE: To investigate the effect of different reference transducer positions on intra-abdominal pressure (IAP) measurement. Three reference levels were studied: the symphysis pubis; the phlebostatic axis; and the midaxillary line at the level of the iliac crest. DESIGN: Prospective cohort study. SETTING: The intensive care units of participating hospitals PATIENTS AND PARTICIPANTS: One hundred thirty-two critically ill patients at risk for intra-abdominal hypertension (IAH). INTERVENTIONS: In each patient, three sets of IAP measurements were obtained in the supine position, using the different reference levels. The IAP measurements obtained at the different reference levels were compared using a paired t-test and Bland-Altman statistics were calculated. MEASUREMENTS AND RESULTS: IAP(phlebostatic) (9.9 +/- 4.67 mmHg) and IAP(pubis) (8.4 +/- 4.60 mmHg) were significantly lower that IAP(midax) (12.2 +/- 4.66 mmHg; p < 0.0001 for both comparisons). The bias between the IAP(midax) and IAP(pubis) was 3.8 mmHg (95% CI 3.5-4.1) and 2.3 mmHg (95% CI 1.9-2.6) between the IAP(midax) and the IAP(phlebostatic). The precision was 3.03 and 3.40, respectively. CONCLUSIONS: In the supine position, IAP(midax) is higher than both IAP(phlebostatic) and IAP(pubis), differences found to be clinically significant; therefore, the symphysis pubis or phlebostatic axis reference lines are not interchangeable with the midaxillary level.

The abdominal compartment syndrome (ACS) in general surgery.

BACKGROUND: The abdominal compartment syndrome is a life threatening clinical entity which can develop within the first 12 hours of intensive care unit admission in high-risk surgical patients. The aim of this paper is to show the definitions, ethiology, pathophysiology, diagnosis and treatment of this serious, not only surgical problem. METHODOLOGY: The mortality due to the abdominal compartment syndrome is extremely high (38-71%). It can be defined as adverse physiologic consequences that occur as a result of an acute increase in the intraabdominal pressure. The most common causes are retroperitoneal haemorrhage, visceral oedema, pancreatitis, bowel obstruction, tense ascites, peritonitis, tumor. The mostly affected systems are cardiovascular, pulmonary, renal, central nervous systems and splanchnic organs. The gold standard diagnostic method is the continuous intra-abdominal pressure monitoring. The treatment consists of adequate fluid resuscitation and surgical decompression. RESULTS: We show three typical short case reports treated by the above mentioned theories. CONCLUSIONS: Intraabdominal hypertension and abdominal compartment syndrome are frequent clinical findings among acute general surgical patients. Patients with comparable demographics and acute severity of illness are more likely to die if intraabdominal hypertension or abdominal compartment syndrome is present. We conclude that the early recognition and surgical decompression is urgent.

[The abdominal compartment syndrome (ACS) in general surgery]. / Abdominális kompartment szindróma (ACS) az általános sebészetben.

Mortality due to the abdominal compartment syndrome is extremely high (38-71%). It may be defined as adverse physiologic consequences that occur as a result of an acute increase in the intraabdominal pressure. The most common causes of abdominal compartment syndrome are retroperitoneal haemorrhage, visceral oedema, pancreatitis, bowel distension, venous mesenterial obstruction, tense ascites, peritonitis, tumor. The mostly affected organ systems include cardiovascular, pulmonary, renal, central nervous and splanchnic. The diagnosis depends on the recognition of the clinical syndrome followed by an objective measurement of intraabdominal pressure, preferably that of the urinary bladder. The treatment consist of adequate fluid resuscitation and surgical decompression when necessary.

[Our experiences during laparoscopic giant paraesophageal hernia repair (1993-2004)]. / Oriás rekeszsérvek laparoszkópos mutétei során szerzett tapasztalataink (1993-2004).

INTRODUCTION: Following both open and laparoscopic surgery for large hiatus hernias the recurrence rate is high. During the last decade we found that the correct indication and operation technique at primary operation should be prophylactic against recurrent hiatus hernia and postoperative dysphagia. MATERIAL AND METHOD: Between 1993 and 2004 more than 350 antireflux procedures were performed in our department. In 35 patients direct crural reconstructions and onlay-mesh implantation was necessary because of extremely large hiatus hernias. The onlay-mesh implantation and tension-free hiatus reconstruction beside correct calibration of the lower esophageal sphincter (LES) decreases the chance of recurrence and postoperative dysphagia. RESULTS: In the early period there were five recurrent hernias due to crural reconstruction with absorbable sutures, weak intracorporally knotted crural sutures and extremely large hiatus hernia. During laparoscopic reoperations reconstructions with onlay mesh implantation were performed successfully. CONCLUSION: The mesh implantation with correct indication and intraoperatively calibrated wrap decrease recurrence and postoperative dysphagia. Laparoscopic reoperation is a safe procedure with good results in trained hands.

[Difficulties in the treatment of polycystic liver]. / A polycystás máj kezelésének nehézségei.

A 52-year-old female patient was admitted to our department suffering from discomfort and tension in right side subcostal region for five months. The anamnesis contains cholecystectomy, appendectomy and gynecology treatment. CT examination and X-ray examination showed cysts in both lobe of liver. The primary treatment was ultrasonography guided punction in another department. This treatment caused anaphylactoid shock. After this dangerous treatment the patient refused the next punction. Following required arrangement laparoscopic exploration and adhaesiolysis were done in our department. Different size cysts had laparoscopically fenestrated. After half year the patient's symptoms resumed. Repeated CT and US examinations showed cysts again. Cysts were laparoscopically fenestrated again. Since the operation the patient had no complaint. Histology showed fibrocystic liver. After a month control CT examination showed cysts again. After two months we made ultrasonography guide punction of remain cysts following radiological consultation.