Introduction
Materials and methods
Definitions
Severe acute pancreatitis (SAP)
Multiple organ failure (MOF)
Intra-abdominal hypertension (IAH)
Abdominal compartment Syndrome (ACS)
Patients
Statistical analysis
Results
Patient characteristics
Intra-abdominal pressure
IAP measurements | No IAP measurements |
p value | |
---|---|---|---|
Number of patients | 29 | 30 | |
Female gender | 7 | 16 |
0.042
|
Age, mean ± SD | 59.6 ± 13.9 | 61.8 ± 13.6 | 0.557 |
Apache II score, mean ± SD | 26.6 ± 7.3 | 26.1 ± 11.8 | 0.849 |
Interval between hospital admission and tertiary ICU admission in days, mean ± SDa
| 9.3 ± 12.2 | 17.2 ± 26.0 | 0.144 |
Any organ failure | 29 (100 %) | 25 (83.3 %) | 0.067 |
Respiratory failure | 29 (100 %) | 24 (80 %) |
0.035
|
Shock requiring vasopressors | 27 (93.1 %) | 19 (63.3 %) |
0.015
|
Renal failure | 24 (82.8 %) | 15 (50 %) |
0.017
|
Known bowel ischemia | 9 | 2 |
0.039
|
Mortality | 11 | 11 | 1.0 |
Days between ICU admission and first IAP measurement, median (IQR) | 1 (0–26) | N/A | |
Highest IAP in mmHg, mean ± SD | 24 ± 5 | N/A | |
Meets criteria for IAHb
| 29 (100 %) | N/A | |
Grade I | 3 (10.3 %) | ||
Grade II | 4 (13.8 %) | ||
Grade III | 9 (31.0 %) | ||
Grade IV | 13 (44.8 %) | ||
Meets criteria for ACSc
| 13 (44.8) | N/A | |
Days between ICU admission and diagnosis of ACS, median (IQR) | 1 (0–13) | N/A |
No ACS (n = 16) | ACS (n = 13) |
p
| |
---|---|---|---|
Characteristics | |||
Female gender | 4 (25.0 %) | 3 (23 %) | 1.00 |
Age, mean ± SD | 64 ± 12 | 55 ± 15 | 0.098 |
APACHE II score, mean ± SD | 26 ± 5 | 28 ± 10 | 0.650 |
Interval between hospital admission and tertiary ICU admission in days, mean ± SD | 13.6 ± 14.6 | 3.8 ± 4.1 |
0.020
|
Grade of IAH | |||
Grade I | 3 (18.8 %) | 0 | |
Grade II | 4 (25.0 %) | 0 | |
Grade III | 4 (25.0 %) | 5 (38.5 %) | |
Grade IV | 5 (31.3 %) | 8 (61.5 %) | |
Any organ failure | 16 (100 %) | 13 (100 %) | 1.00 |
Respiratory failure | 16 (100 %) | 13 (100 %) | 1.00 |
Shock requiring vasopressors | 14 (87.5 %) | 13 (100 %) | 0.488 |
Renal failure | 11 (68.8 %) | 13 (100 %) |
0.048
|
Multiple organ failure | 15 (93.8 %) | 13 (100 %) | 1.00 |
Infected pancreatic necrosis | 12 (75.0 %) | 9 (69.2 %) | 1.00 |
Surgical treatment | |||
Radiological drainage | 9 (56.3 %) | 8 (61.5 %) | 0.774 |
VARD | 6 (37.5 %) | 8 (61.5 %) | 0.198 |
Necrosectomy via laparotomy | 6 (37.5 %) | 2 (15.4 %) | 0.238 |
Decompression laparotomy | 2 (12.5 %) | 10 (76.9 %) |
<0.001
|
Outcome | |||
Bowel perforation or fistula | 6 (37.5 %) | 6 (46.2 %) | 0.638 |
Gastrointestinal ischemia or necrosis | 1 (6.3 %) | 8 (61.5 %) |
0.003
|
Length of ICU stay in days, median (IQR) | 21 (4–86) | 48 (1–135) | 0.116 |
Mortality | 4 (25.0 %) | 7 (53.8 %) | 0.143 |
Treatment of ACS
Patient | Time from diagnosis ACS to decompressive surgery (h) | Lactate pre-operative (mmol/L) | Lactate post-operative (mmol/L) | Ischemia present/absent | Improvement after decompression |
---|---|---|---|---|---|
1 | No decompression | 15 (before death) | N/A | Present (autopsy) | N/A |
2 | No decompression | 1.3 | N/A | N/A | |
3 | No decompression | 1.3 | N/A | N/A | |
4 | 2 | 3.2 | 3.5 | Absent | Yes, respiratory and diuresis No hemodynamic improvement |
5 | 176 | 0.8 | 0.8 | Absent | No |
6 | 4 | 1.4 | 2.7 | Absent | Yes, respiratory |
7 | 10 | 6.4 | 4.1 | Present | No, persistent high IAP. Relaparotomy: ileum resection and new stoma |
8 | 19.5 | 1.6 | 1.5 | Present | Yes, respiratory and hemodynamic. IAP persistent high. |
9 | 23.5 | 1.1 | 1.9 | Present | No |
10 | 37 | 6.4 | 11.5 | Present | Yes, respiratory. Hemodynamics very unstable, relaparotomy: sigmoid necrosis, 2 gastric perforations |
11 | 2 | 9.2 | Present | No, treatment withdrawal and death | |
12 | 14 | 8.3 | 9.2 | Present | No, persistent high IAP |
13 | 2 | 2.4 | 2.2 | Present | No, persistent high IAP. Relaparotomy: Ischemia left colon and coecum |
Effect of decompressive laparotomy
Intra-abdominal ischemia and outcome
Pt nr. | Max IAP | Macroscopy | Microscopy | Outcome |
---|---|---|---|---|
1 | 22 | Autopsy findings: Focal ischemia on serosal and mucosal side of small bowel | Mucosa of jejunum and colon almost completely disappeared | Died 2 days after admission to the ICU |
7 | 24 | Full necrosis of the sigmoid | Transmural ischemic necrosis sigmoid | Died 67 days after decompression due to bleeding complications caused by pancreatitis |
8 | 26 | Dubious signs of ischemia of terminal ileum | Segmental chronic and acute inflammation with perforation; concordant with ischemic enteritis | Died 40 days after decompression due to sepsis and MOF |
9 | 27 | Firm necrosis of the jejunum | Severe transmural ischemic enteritis | Discharge to ward 134 days after decompression |
10 | 27 | Only necrotic remains of the sigmoid colon | Transmural necrosis | Died 13 days after decompression due to sepsis and MOF |
11 | 29 | Full black necrosis of small and large intestine | Not available | Died several hours after decompression, after withdrawal of treatment |
12 | 32 | Marbled aspect of left liver lobe | Not available | Died 47 days after decompression, due to sepsis and MOF |
13 | 32 | Patchy and full ischemia of the terminal ileum; full ischemia of cecum and left colon | ischemia ileum, cecum and left colon | Discharge to ward 16 days after decompression |
Discussion
Limitations of this study
Conclusion
Key messages
-
Intra-abdominal hypertension and abdominal compartment syndrome are common in patients with severe acute pancreatitis
-
Intra-abdominal ischemia may complicate the course of pancreatitis and ACS
-
Routine measurement of IAP is advised in all patients with severe acute pancreatitis.