Application of pie-crusting technique to facilitate closure of open abdomen after decompressive laparotomy

We present the case of a 23-year-old man who developed abdominal compartment syndrome secondary to severe pancreatitis and required decompressive laparotomy and pancreatic necrosectomy. Despite application of a temporary abdominal closure system (ABThera Open Abdomen Negative Pressure Therapy), extensive retroperitoneal oedema and inflammation continued to contribute to loss of domain and prevented primary closure of the skin and fascia. The usual course of action would have involved reapplication of ABThera system until primary closure could be achieved or sufficient granulation tissue permitted split-thickness skin grafting. Though a safe option for abdominal closure, application of a skin graft would delay return to baseline functional status and require eventual graft excision with abdominal wall reconstruction for this active labourer. Thus, we achieved primary closure of the skin through the novel application of abdominal wall ‘pie-crusting’, or tension-releasing multiple skin incisions, technique.

Abdominal compartment syndrome secondary to chronic constipation in MECP2 duplication syndrome

Abdominal compartment syndrome (ACS) is an infrequently encountered life-threatening disorder characterised by elevated abdominal pressure with evidence of new organ dysfunction. It is rarely reported in paediatrics. We describe an extremely unusual presentation of a 13-year-old boy with long-standing constipation who developed ACS complicated by refractory septic shock and multiorgan failure. He was treated with emergent decompressive laparotomy and supportive critical care. This case highlights the need for early diagnosis and timely management of ACS to improve its outcome.

Management of intra-abdominal hypertension during ECMO: Total water-assisted colonoscopy as a step-up minimally invasive treatment, and a literature review

Background and study aims During extracorporeal membrane oxygenation (ECMO), intra-abdominal hypertension (IAH) can impair ECMO venous drainage, reducing its ability to provide an adequate oxygenated blood flow. When medical therapy is ineffective in managing IAH, guidelines recommend a decompressive laparotomy (DL), though the procedure is associated with several complications and poor outcomes. Patients and methods This was a case series of IAH in patients affected with acute respiratory distress syndrome (ARDS) on veno-venous (V-V) ECMO, in whom we performed total water-assisted colonoscopy (t-WAC) to treat IAH. Results In three patients who underwent t-WAC, we report a real-time intra-procedural reduction of IAH, normalization of ECMO blood flow, and a reduction of vasopressors and lactates. t-WAC was performed in the context of evident abdominal compartment syndrome with multiorgan failure, and in one case was performed because of IAH and ECMO impairment. One patient was discharged alive, while the other two died of multiorgan failure, although the cause of death was apparently not secondary to IAH. Conclusions During ECMO, in select cases,T-WAC may represent a first-line non-invasive approach.

Need for Screening Triglyceride Levels in Women on Oral Contraceptives

Introduction: Oral contraceptive pills (OCPs) are the most used form of reversible contraceptives by women. Major risks are cardiovascular but OCPs also cause secondary hypertriglyceridemia (HTG) through effects of estrogen, which decreases hepatic triglyceride lipase and lipoprotein lipase activity. This causes increased triglycerides, cholesterol and free fatty acids,1 which then in turn can lead to life-threatening acute pancreatitis. Case Description: A 23-year-old morbidly obese (BMI 38.2 mg/kg2) female presented with severe epigastric pain, nausea and vomiting. She had a history of mild intermittent asthma, recently diagnosed pre-diabetes and recently started on OCPs. Initial labs were consistent with diabetic ketoacidosis with glucose 528 mg/dL (65-115 mg/dL), anion gap 21 mEq/L (5-15 mEq), and beta-hydroxybutyrate 2.00 mmol/L (0.02-0.27 mmol/L); and acute pancreatitis with triglyceride 4,425 mg/dL (30-200 mg/dL) and lipase >600 U/L (8-78 UL), confirmed on imaging. She rapidly deteriorated, developing acute hypoxemic respiratory distress requiring intubation and distributive shock requiring three vasopressors. She progressed into multi-organ failure with acute respiratory distress syndrome, ischemic liver and acute renal failure despite insulin drip, colloidal fluid resuscitation, continuous veno-venous hemofiltration and high positive end-exploratory pressures. She developed rhabdomyolysis, followed by abdominal compartment syndrome requiring decompressive laparotomy that resulted in large volume blood loss and retroperitoneal necrosis needing multiple laparotomies. Ultimately, she became non-responsive off sedation, attributed to malignant cerebral edema that progressed to brain herniation. While HTG was likely the cause of her pancreatitis, she had normal triglyceride levels on prior routine lab work while not on OCPs. Discussion: Severe acute pancreatitis is a life-threatening complication of HTG which may be precipitated by use of OCPs. We believe that there is a need for more research in this field and even propose periodic monitoring of HTG in women taking OCPs given the severity of the consequences. While there are currently no guidelines for monitoring lipid levels in women on OCP, appropriate clinical awareness of physicians prescribing OCPs to patients may prevent fatal outcomes. References: 1. Stumpf, M., Kluthcovsky, A., Okamoto, J., Schrut, G., Cajoeiro, P., Chacra, A. and Bizeli, R. (2018). Acute pancreatitis secondary to oral contraceptive-induced hypertriglyceridemia: a case report. Gynecological Endocrinology, 34(11), pp.930-932.

Hyperglycemia, Hypertriglyceridemia and Acute Pancreatitis in COVID-19 Infection

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection primarily affects the respiratory tract, but gastrointestinal (GI) symptoms may obscure a secondary diagnosis. GI symptoms similar to the ones presented in acute pancreatitis (AP) have been reported. SARS-CoV-2 binds to angiotensin-converting enzyme 2 receptors, which have been identified in the lungs and pancreas. It has been discussed that systemic response to the infection prompts dysregulation in the affected organs. Hyperglycemia is an independent risk factor for increased mortality and thus a detailed assessment must be performed. A 47 year-old man with dyslipidemia arrived at the ER due to a severe constant epigastric pain of 1 day of evolution with back radiation associated with nauseas, emesis, and hyporexia. Upon examination he was tachycardic and in distress due to pain. Laboratories revealed normocytosis, normal hemoglobin, mild thrombocytopenia, hyperglycemia (150 mg/dL), corrected hyponatremia (130 mmol/L), and corrected hypocalcemia (7.4 mg/dL). Amylase (2,332 U/L) and lipase (2,990 U/L) were elevated. Triglycerides were 6,256 mg/dL and glycated hemoglobin was 6.1%. Abdominal CT scan revealed pancreatitis. He was admitted to the ICU due to severe AP due to hypertriglyceridemia with IV hydration and IV insulin infusion. During the first day of admission, he developed respiratory distress requiring intubation, marked abdominal distension, hemodynamic instability, and oliguria. Intra-abdominal pressure yielded 24 mmHg leading to the diagnosis of abdominal compartment syndrome. He underwent emergent abdominal decompressive laparotomy with Bogota Bag placement. COVID-19 PCR test was performed and reported positive. 72 hours later, triglycerides improved and IV insulin was discontinued, but hyperglycemic state prompted subcutaneous basal and correction boluses. Insulin requirement progressively decreased and was discontinued after 14 days. He continued to show clinical improvement and by day 40, the patient was successfully extubated and discharged after physical rehabilitation. SARS-CoV-2 infection has shown a complex multisystem involvement leading to variable presentations which can be fatal if not identified and addressed properly. Albeit, AP is a rare manifestation of COVID-19, clinicians should be aware and pay attention to the related complications. Proposed mechanisms for hyperglycemia and AP include β-cell damage. The pathogenetic role of COVID-19 in hypertriglyceridemia is unclear. Little attention has been paid to the extent of pancreatic injury caused by this virus. To our knowledge this is the second case presenting with hyperglycemia, hypertriglyceridemia, and AP in COVID-19 infection. As the global pandemic is still growing, elucidation of key pathways and mechanisms underlying these associations would aid in the treatment of patients with COVID-19 worldwide.

Abdominal Compartment Syndrome

Abdominal compartment syndrome (ACS) is a progressively increasing intraabdominal pressure of more than 20 mm Hg with new-onset thoracoabdominal organ dysfunction. Primary abdominal compartment syndrome means increased pressure due to injury or disease in the abdominopelvic region. Secondary abdominal compartment syndrome means disease originating from outside the abdomen, such as significant burns or sepsis. As the pressure inside the abdomen increases, organ failure occurs, and the kidneys and lungs are the most frequently affected. Managements of ACS are multidisciplinary. Conservative treatment with adequate volume supple and with aggressive hemodynamic support is the first step. Decompressive laparotomy with open abdomen is indicated when ACS is refractory to conservative treatment and complicated with multiple organ failure. ACS can result in a high mortality rate, and successful treatment requires cooperation between physicians, intensivists, and surgeons.

Secondary ARDS Following Acute Pancreatitis: Is Extracorporeal Membrane Oxygenation Feasible or Futile?

Objective: To assess the feasibility of extracorporeal membrane oxygenation (ECMO) or life support (ECLS) as last resort life support therapy in patients with acute pancreatitis and subsequent secondary acute respiratory distress syndrome (ARDS). Methods: Retrospective analysis from January 2013, to April 2020, of ECMO patients with pancreatitis-induced ARDS at a German University Hospital. Demographics, hospital and ICU length of stay, duration of ECMO therapy, days on mechanical ventilation, fluid balance, need for decompressive laparotomy, amount of blood products, prognostic scores (CCI (Charlson Comorbidity Index), SOFA (Sequential Organ Failure Assessment), RESP(Respiratory ECMO Survival Prediction), SAVE (Survival after Veno-Arterial ECMO)), and the total known length of survival were assessed. Results: A total of n = 495 patients underwent ECMO. Eight patients with acute pancreatitis received ECLS (seven veno-venous, one veno-arterial). Five (71%) required decompressive laparotomy as salvage therapy due to abdominal hypertension. Two patients with acute pancreatitis (25%) survived to hospital discharge. The overall median length of survival was 22 days. Survivors required less fluid in the first 72 h of ECMO support and showed lower values for all prognostic scores. Conclusion: ECLS can be performed as a rescue therapy in patients with pancreatitis and secondary ARDS, but nevertheless mortality remains still high. Thus, this last-resort therapy may be best suited for patients with fewer pre-existing comorbidities and no other organ failure.

Management of Incarcerated Indirect Hernia in Pediatric Patients with Intra-abdominal Hypertension: A Retrospective Study

Background: Intra-abdominal hypertension (IAH) is a critical condition that can be induced by incarcerated indirect inguinal hernia (IIIH). There are currently no specific guidelines for laparotomy in children. To determine whether laparotomy should be performed during the management in pediatric patients with IIIH combined with IAH.Methods: This is a retrospective study of pediatric patients with IIIH and IAH who were admitted and treated at the Department of General Surgery of Jiangxi Provincial Children’s Hospital from 01/2010 to 06/2020. The patients were divided into Group A (intra-abdominal pressure (IAP) of 10-20 mmHg) and Group B (IAP ≥ 21 mmHg). Each group was further subdivided into Group 1 (decompression) and Group 2 (no decompression) depending on whether decompressive laparotomy was performed or not. The last follow-up was three months after discharge.Results: A total of 49 patients were enrolled, and divided into group A1 (n = 21), A2 (n = 10), B1 (n = 4), B2 (n = 14). Compared with patients in group A1, those who had decompression (group A2) has longer hospital stay (7.5 ± 1.9 vs. 5.2 ± 2.1, p = 0.01), higher 24h-postoperative IAP (11.3 ± 2.4 vs 9.5 ± 2.1, p = 0.03), longer PICU stay (2.1 ± 0.9 vs. 1.1 ± 0.5, p = 0.001), and more perioperative complications. In contrast, among patients with IAP higher than 20mmHg, those who had decompresion via laparotomy (group B2) had comparable hospital stay (7.1 ± 5.1 vs. 8.5 ± 4.1, p = 0.57), a shorter PICU stay (3.0 ± 1.4 vs. 4.7 ± 1.3, p = 0.04) and lower mortality rate (7.1% vs. 50%, p = 0.04) than patients in group B1.Conclusions: The selection of appropriate surgical methods according to IAP and based on clinical diagnosis can relieve the pain of children, shorten hospital stay, and reduce the mortality rate.

Open Abdomen during Extracorporeal Membrane Oxygenation is a Safe and Effective Treatment for Abdominal Compartment Syndrome

Background/Purpose Historically, decompressive laparotomy and open abdomen for abdominal compartment syndrome has contraindicated Extracorporeal Membrane Oxygenation (ECMO) due to seemingly high risk of bleeding and infection. The literature shows few examples of this treatment, and the existing studies are inconclusive. The purpose of this study was to review the series at Riley Hospital for Children and evaluate the effectiveness of ECMO treatment for patients undergoing decompressive laparotomy with open abdomen to recommend future care guidelines. Methods We reviewed all pediatric (30 days to 18 years) patients treated with ECMO concurrently with decompressive laparotomy and open abdomen at Riley Hospital for Children from 2000-2019. We compared these patients with non-surgical pediatric patients supported with ECMO for respiratory failure at Riley Hospital for Children during the same period. Demographics, ECMO data, and outcomes were assessed. We performed t-test, ROC, and chi-square analyses. We defined significance as p=0.05. Results 5 of 82 pediatric respiratory ECMO patients were treated with decompressive laparotomy and open abdomen. Survival among the surgical group was 60%, compared to 57% in the non-surgical group (p=0.9). Surgical patients had a similar incidence of bleeding complications (40%) compared to non-surgical patients (55.8%), p=0.486. Surgical patients had a significantly higher VIS (3126 vs 19.2, p=0.004), PaO2/FiO2 ratio (279.0 vs 72.9, p=0.031), and pump flow rate at 24hrs (112mL/kg/min vs 88.1mL/kg/min, p=0.045) than non-surgical patients, while receiving a similar volume of PRBCs (p=0.581) and requiring ECMO treatment for a similar amount of time (p=0.511). Conclusion/Potential Impact ECMO support in patients with decompressive laparotomy and open abdomen was associated with similar survival and bleeding complications compared to non-surgical ECMO patients. ECMO should be offered to or continued in eligible patients with abdominal catastrophe, as it is effective in supporting organ function while not significantly increasing the risk for complications.