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8IMPROVEMENT OF DIAGNOSTIC-THERAPEUTIC ALGORITHM FOR ACUTE SURGICAL ABDOMINAL PATHOLOGY COMPLICATED BY INTRA-ABDOMINAL HYPERTENSION
Kolosovych A.
Postgraduate Student of the Surgery Department #2, Master of Surgery Bogomolets
National Medical University, Kyiv, Ukraine,
Abstract
Acute abdominal pathology may cause a progressive, unchecked increase of intra-abdominal pressure (IAP) up to the development of the intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS). Were enrolled 187 patients with acute abdominal surgical pathology, clinical signs of IAH and detected raised IAP. We used new three stage treatment approach. Usage of the simplified algorithm for correction of intra-ab-dominal pressure has allowed a statistically significant reduction of the number of systemic complications in patients with urgent pathology of abdominal organs.
Keywords: Abdominal compartment syndrome, acute surgical pathology, intra-abdominal pressure, intraabdominal hypertension.
INTRODUCTION
Despite intuitive comprehension of the role of increased abdominal pressure on the course of acute and chronic abdominal pathology, real understanding and scientific substantiation of the problem came only in recent years [1,4,5,8]. Progressive, unchecked increase in intra-abdominal pressure may lead to intra-abdominal hypertension (IAH) and then to the abdominal compartment syndrome (ACS), which is defined by the consensus definitions of the World Society of the Abdominal Compartment Syndrome (WSACS) as a sustained in-tra-abdominal pressure (IAP) > 20 mmHg that is associated with new organ dysfunction/failure [6,7,16]. The WSACS has created three algorithms detailing the current state-of-the-art diagnosis and management of IAH/ACS: the IAH Assessment [16], the IAH/ACS Management, and IAH/ACS Medical Management algorithms [6,7]. Elaboration of new technical and tactical approaches to prevention and treatment of ACS in patients with acute surgical pathology of abdominal viscus is of current importance.
The first understanding of the negative pathophysiological influence of increased abdominal pressure on blood circulation and external breathing after blunt abdominal trauma became a stimulus for future evaluation of IAP in critically ill patients with other diseases [10]. Soon investigators found that ACS may complicate the course of acute pancreatitis [11,15], peritonitis [9] and acute bowel obstruction [10]. Abdominal hypertension does not obligatory lead to ACS but the tendency of its growth in surgical patients was found [13].
For successful management of IAH clear understanding of etiological factor is essential. The main idea of management is to maintain IAP < 15 mmHg. The rationales for choosing this level of pressure were the following considerations. First of all, at this pressure
reduction in microcirculatory blood flow occur [3] and oliguria develops [2,12]. Then, we took into account our previous experience of patients managing after her-nioplasty [17]. Finally, this level was proposed in the second consensus of WSACS [6].
The aim of this study was to optimise the nonsur-gical ways of abdominal decompression to prevent abdominal compartment syndrome development in patients with the acute diseases of abdominal organs that cause intra-abdominal hypertension.
MATERIALS AND METHODS
In this retrospective and prospective study, conducted in the Department of Surgery #2 of Bogomolets National Medical University (Kyiv, Ukraine), were enrolled 187 patients with acute abdominal surgical pathology, clinical signs of IAH and detected raised IAP. In the studied group, there were 117 (62.5%) males and 70 (37.4%) females. Their age varied from 21 to 85 yrs., average 46.5 ± 1.12 yrs. Depending upon the tactical approach used, patients were divided into two groups: the main one and control. Control group consisted of 85 (45.5%) patients who were treated in a standard way; mean different measures for IAP reduction were used on demand without a strict system. Case histories of these patients were analysed retrospectively. The main group included 102 (54.5%) patients to whom optimised therapeutic approach for IAP reduction and ACS prevention was used. These patients were admitted to the clinic in the order of the first aid between January 2014 and December 2016. This group was studied prospectively. Intra-abdominal pressure was measured via an open bladder catheter after 25 mL of sterile saline instillation. Adding a laser pointer and a level to the system (Figure 1) permitted its zeroing without direct physical contact with the patient's trunk.
Figure 1. Modified system for IAP measurement: 1 - Level, 2 - Laser pointer, 3 - Y-tube, 4 - Foley catheter, 5 - Tape-line, 6 - Level of water, 7 - Syringe.
This was especially useful during surgery to avoid contact with the sterile surgical field. Measurements were taken before surgery, at its different stages, especially before and after abdominal wall closure, and in the intensive care unit. For diagnosis of acute abdominal pathology ultrasound, CT and endoscopy, as well as physical examination and routine laboratory studies, were used. .The clinical outcome measures were: frequency of systemic and local complications, mortality and causes of death in both groups.
Statistica 8.0 (Statsoft Inc., Tulsa OK Oklahoma, USA) software was used for the data processing.
Graphical assessment of normality was supplemented by Shapiro-Wilk test [14]. Intra-abdominal pressure in patients with acute pancreatitis was presented as "mean ± SD". The means for two independent normally distributed groups were compared by an independent samples t-test, for two dependent groups - by dependent samples t-test. Differences between the samples were considered statistically significant when p-value < 0.05.
RESULTS AND DISCUSSION More than half of both groups consisted of patients with acute pancreatitis and abdominal trauma (Table 1).
Table 1
The diagnosis in the patients of both groups
Nosology Patients with systemic complications (n=32)
Study group n=102 Control group n=85 Total n=187
n % n % n
Strangulated ventral hernia 15 14.7 13 15.3 28
Acute pancreatitis 18 18.6 17 20.0 35
Acute bowel obstruction 17 16.7 13 15.3 30
Acute appendicitis 13 12.7 9 11.6 22
Acute cholecystitis 12 11.8 10 11.8 22
Blunt abdominal trauma 19 18.6 17 20.0 36
Perforated duodenal ulcer 6 5.9 5 5.9 11
Perforated tumours 2 1,9 1 1.2 3
Total 9 28.1 23 71.9 32
Immediate surgery has been undertaken in 149 patients (79.7%). Thirty-eight patients (29.2%) were managed medically: 29 with acute pancreatitis, 9 with peritoneal adhesions. For big size and giant ventral strangulated hernias simple or mesh repair was performed, controlling intraoperatively IAP. All patients with acute appendicitis, acute cholecystitis and perforated duodenal ulcers were admitted with severe peri-
tonitis and ileus. Patients with appendicitis and cholecystitis had concomitant obesity (BMI > 30 kg/m2). Surgical approach to bowel obstruction management was determined considering its aetiology. To reduce the invasiveness of the acute pancreatitis surgical treatment to the maximum, repeated drainage of abdominal fluid accumulations under ultrasound control and seques-trectomy through small incisions were performed.
A retrospective assessment of the control group patients showed that from the perspective of the current understanding of this pathology, not all possibilities of conservative treatment were used. Thus the approach to IAH management was optimised in the following way. After IAH verification, a decision about the tactics of treatment was made. First of all, it depended upon the etiological factor. Excluding strangulated hernia, the main cause of abdominal pressure rise was an increase in the volume of abdominal content (bowel paresis, accumulation of free fluid, limited liquid formations). In elderly overweight patients with a hernia, IAH developed due both to decrease in the volume of the abdominal cavity and intestine paresis. According to the international recommendations, management of IAH/ACS started beginning from medical and minimally invasive therapies (Kirkpatrick et al., 2017). Recognizing that the proposed by WSACS IAH/ACS management and IAH/ACS medical management algorithms encompass all currently known aspects of the IAH correction and treatment of ACS, we have created a slightly modified and shorter conservative treatment algorithm for our daily work. It includes therapeutic methods available to us (Figure 2).
As well as in the above-mentioned algorithms, interventions were applied in a stepwise fashion. In case of no response to a particular intervention, therapy escalated to the next step in the algorithm. The proposed algorithm consists of 3 levels of increasing complexity. The differences between our algorithm and the one proposed by the WSACS are as follows. Since many of the patients with registered IAP > 12 mmHg were on artificial ventilation of the lungs, resetting of a ventilator was introduced at the first stage. It made possible quickly normalize IAP in some patients. We shifted enema to the first step of treatment as a cheap, not time consuming but effective procedure. Antiflatulent drugs and enzymes we also added to the first step. Surgical evacuation of lesions was excluded from the third step since this is a surgical procedure. Epidural anaesthesia was introduced instead. The proposed algorithm has demonstrated convenience for routine use. The main purpose of all treatment affords was to maintain IAP < 15 mmHg. From the moment when bladder pressure was registered at the level of 12 mmHg or more, repeated measurements every 6 hours were started. Management of the patients on mechanical ventilation started from the regulation of ventilator's parameters -tidal volume was reduced with a proportional increase of respiratory rate.
IAP > 12 mmHg
a
a
Monitoring of IAP (every 6 hours) Purpose - maintain IAP < 15 mmHg
Mechanical ventilation
Resetting of ventilator: reduction of tidal volume; increase respiratory rate PIP should not exceed 30 cmH2O
Spontaneous breathing
* '__ r
Decrease of the volume of abdominal content
i r
Decompression of GI tract
Effective
• sedation
• analgesia
Remove constric-tive dressings from the trunk Nasogastric tube Enema
• antiflatulents
• prokinetics
• enzymes
2 a
a
cr¡
US guided transcuta-neous drainage of fluid accumulations
a
Diuretics in stable patients
Neuromuscular blockade
Epidural anesthesia
Optimization of fluid balance
• -zero to negative
• resuscitation with hypertonic fluids and colloids
Colonoscopic decompression
Discontinuance of enteral tube nutrition
If after third step activities IAP > 20 mmHg
1 r
Surgical decompression
Peak inspiratory pressure should not exceed 300 mmH2O (22,2 mmHg). In 49 (59.8%) patients, who were on mechanical ventilation, the target pressure less than 15 mmHg was achieved after average decreases of IAP on 18.8 ± 2.6 mmHg.
Thus there was no need to move to the next stage, only monitoring of IAP was continued. In the remaining patients on mechanical ventilation, in whom this manoeuvre was not completely effective, and in all patients with spontaneous breathing efforts were undertaken to improve abdominal wall compliance - all con-strictive dressings and bandages were removed from the trunk and adequate analgesia and sedation were provided. After that, the number of patients in whom IAP achieved an acceptable level increased to 24 mmHg.
Abdominal content volume decreased at this stage due to: 1) decompression of upper gastrointestinal tract with a nasogastric tube and of the colon - by enema; 2) reduction of meteorism - by antiflatulents, prokinetics and enzymes. All complex of the first step measures permitted to stabilize IAP on the target level with subsequent normalization in 69 (67.6%) patients. In the case of uneffectiveness of the first stage activities, therapy was escalated to the second step which included: 1) transcutaneous drainage of fluid accumulations under ultrasound control in patients with acute pancreatitis; 2) optimization of fluid administration (zero to negative balance, utilization of hypertonic fluids and colloids, administration of diuretics in hemodynamically stable patients); 3) minimization of the tube enteral nutrition and avoidance of high concentration solutions. In 23 cases (22.5%) IAP was reduced to the safe level by drainage of fluid accumulations.
Patients who were refractory to conservative treatment had to pass to the third step. From our point of view, the most effective manoeuvre on this stage was the improvement of abdominal wall compliance. If mechanical ventilation was continued, preference was given to neuromuscular blockade, in spontaneously breathing patients - epidural anaesthesia. Enteral tube feeding was completely discontinued in all patients. We suppose that on this stage colonoscopic decompression may also be considered, although in the group we examined there were no such cases.
If, after using the entire arsenal of 3 -step conservative treatment, it was not possible to achieve a reduction in IAP, on the contrary, it increased to 20 mmHg or more, there was a need for surgical decompression. Described algorithm permitted to reduce IAP and escape
surgical decompression at all patients of study group. At the same time, the need for this intervention arose in 2 patients from 18 comparison groups (11.1%) who were treated conservatively.
It is clear that the stage-by-stage approach to the management of patients with such pathology is somewhat relative. For example, correction of ventilator's settings demonstrates greater efficiency against the background of the use of neuromuscular blockade. Set of activities may vary depending on the specific surgical pathology.
Keeping in mind that it is better to prevent some complication than make heroic efforts fighting with it, surgical interventions for strangulated hernia, mean interventions that reduce the volume of the abdominal cavity, were performed with the obligatory control of IAP after the closure of fascia and skin. Our previous experience of abdominoplasty and hernia repair demonstrated that increase of IAP to the level of 15 mmHg at the end of elective surgery did not lead to any problems in postoperative period if careful monitoring of the patient's condition was held. Increase of maximum inspiration pressure by 200 mmH2O (14,8 mmHg) and more with unchanged parameters of artificial ventilation of the lungs during the operation may indicate a significant increase in IAP and requires a mandatory check of the latter [17]. The same approach was transferred to the treatment of patients with acute surgical pathology. Dynamics of IAP reflects the effectiveness of used treatment methods.
Very indicative it was in the patients of the most frequent diagnosis - with acute pancreatitis: 18 from the study group versus 17 from the control one. At admission, I grade IAH registered in six patients of each group, II grade - in nine patients of each group and III - in three patients of the study group and two patients of the control group. At the beginning of the treatment average IAP in both groups exceeded 15 mmHg and was almost the same. A statistically significant decrease in IAP was noted in both the primary and control groups by the end of the first week. But from the third-day pressure reduction was statistically faster in patients managed in accordance with proposed algorithm and on the seventh day it was lower (13.2 ± 2.62 vs 16.0 ± 4.37, p = 0.025). Abdominal pressure increase to the level of more than 20 mmHg on the second-third day of treatment was accompanied by worsening of the clinical picture, laboratory and ultrasound data in patients of the control group. (Figure 3).
26
12 I 1
10
8 -■-■-■-■-■-■-■-■-
Initial 1 2 3 4 5 6 7
Day of treatment
£ Study group J Control group Mean; Whisker: Mean±SD
Figure 3. Dynamic of intra-abdominal pressure in patients with acute pancreatitis depending of treatment
Due to the ineffectiveness of conservative treatment, two patients in the control group underwent forced decompressive laparotomy. Uncontrolled multiple organ failure led to the death of 6 patients. By the end the seventh day the average IAP in the control group left higher 15 mmHg. The study group showed a gradual decrease of IAP during one week, and at the end of this period abdominal pressure reduced to the target level (< 15 mmHg). It is understandable that the subsequent dynamics of IAP was dependent on the severity of morphological changes in the pancreas and surrounding tissues. In six cases increase of abdominal pressure promoted transcutaneous ultrasound-guided puncture of fluid accumulations or surgery. Systematic step by step approach in accordance with described algorithm allowed avoiding uncontrolled IAP rise and the development of multiple organ failure. Normalization of intestinal function (decrease of bloating, the spontaneous passage of flatus and stool) and essential reduction of IAP were achieved in 16 (88.9%) patients from
the main group and only in 10 (58.8%) patients from the control group (p < 0.05). Uncontrolled multiple organ failure led to the death of one patients. The application of the proposed algorithm led to a reduction in the incidence of complications in patients with acute pancreatitis from 52.9% to 16.7% (p=0.03), as well as the overall mortality rate - from 35.3% to 5.6% (p=0.03).
The same tendency of IAP dynamic was observed in patients with other urgent abdominal pathology. Analysis of the results of management of patients with acute abdominal surgical pathology demonstrated a statistically significant difference in frequency of systemic complications - 11.8% in the study group and 54.1% in control group, p < 0.0001. Systemic complications (acute insufficiency of one or more systems, thrombo-embolic complications) arose in 12 patients from main group versus 46 patients from control group. The most unfavourable situation developed in case of fairly rapid increase of IAP (Table 2).
Table 2
Frequency of systemic complications in patients with acute surgical pathology of the abdominal cavity, _accompanied by IAH/ACS_
Complications Groups of patients
Study group Control group Total
n % n % n
Acute respiratory insufficiency 6 5.9 18 21.2 24
Heart failure 4 3.9 10 11.8 14
Acute liver failure 1 0.9 1 1.1 2
Multiple organ failure 1 0.9 12 14.1 13
Thromboembolic complications - - 5 5.9 5
Total 12 11.8 46 54.1 58
This happened due to the accumulation of fluid inside the intestine in acute bowel obstruction, the fast formation of liquid accumulations in acute pancreatitis,
hernioplasty under tension. Detailed analysis shows that the most frequent systemic complications were
acute respiratory insufficiency, heart failure and multiple organ failure. A total of 20 patients died (10.7%). Two main group patient (1.96%), conservatively treated for acute pancreatitis and operated with blunt abdominal trauma, died from multiple organ failure. From 18 deceased control group patients (21.2%) ten died from multiple organ failure, one from acute liver insufficiency, two from heart failure and five from pulmonary embolism. The difference in mortality between groups was statistically significant (p < 0,0001). Among the deceased patients from control group, six were with acute pancreatitis, tree were treated for bowel obstruction, four were for strangulated ventral hernia, tree were for acute peritonitis and two for blunt abdominal trauma (1 - pancreatic damage and 1 - spleen rupture). Thus, overall postoperative mortality was 10.7%. Among the causes of death, the first place unconditionally took multiple organ failure - 12 cases (60.0%).
CONCLUSIONS
1. In order to find the optimal way of IAH/ACS management it is necessary clearly understand the causes of its development and underlying pathophysiological mechanisms in a particular case - this is the result of an increase of abdominal content volume or a reduction in the volume of the abdominal cavity.
2. At the first step of the correction of the IAH, it is fundamental to know whether the patient is on mechanical ventilation.
3. Usage of the proposed diagnostic-therapeutic algorithm in the complex treatment of patients with acute pathology of abdominal organs, accompanied by IAH allowed to achieve the intended goal of improving the treatment results of this category of patients by reducing the frequency of development of systemic complications from 54.1% to 11.8 % (p <0.0001), total mortality from 21.2% to 1.96% (p <0.0001).
4. The main cause of the lethal outflow in patients of both groups with the ACS was multiple organ failure (60%).
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