Abdominal Compartment Syndrome: Current Problems and New Strategies

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World J Surg (2008) 32:13–19 DOI 10.1007/s00268-007-9286-x

Abdominal Compartment Syndrome: Current Problems and New Strategies Cem Kaan Parsak Æ Gulsah Seydaoglu Æ Gurhan Sakman Æ T. Oguz Acarturk Æ Emre Karakoc Æ Ismail Hanta Æ Ali Haydar Alparslan Æ Salim Satar

Published online: 17 November 2007 Ó Socie´te´ Internationale de Chirurgie 2007

Abstract Background Abdominal compartment syndrome (ACS) is a diffucult entity with two main problems during its course: (1) survival of the patient during the early period and (2) closure of the open wounds during the late period. In this study we evaluated the decision to decompress according to the level of intraabdominal pressure (IAP) and analysis of any recurrent or persistent increase in IAP. Methods A prospective study was undertaken on 119 patients with increased IAP. The IAP was measured daily by obtaining the bladder pressure. Patients were monitored via a central venous line; and vital signs, arterial blood

C. K. Parsak (&)  G. Sakman  A. H. Alparslan Department of General Surgery, Cukurova University, School of Medicine, 01330, Balcali, Adana, Turkey e-mail: [email protected] G. Seydaoglu Department of Bioistatistics, Cukurova University, School of Medicine, 01330, Balcali, Adana, Turkey T. O. Acarturk Department of Plastic, Reconstructive, and Aesthetic Surgery, Cukurova University, School of Medicine, 01330, Balcali, Adana, Turkey E. Karakoc Department of Intensive Care Unit, Cukurova University, School of Medicine, 01330, Balcali, Adana, Turkey I. Hanta Department of Chest Disease, Cukurova University, School of Medicine, 01330, Balcali, Adana, Turkey S. Satar Department of Emergency Medicine, Cukurova University, School of Medicine, 01330, Balcali, Adana, Turkey

gases, the Acute Physiology, Age, and Chronic Health Evaluation II (APACHE II) score, and abbreviated mental tests were recorded. The suggestions of Meldrum et al. were taken as a guideline during the treatment. The sensitivity and specifity of IAP and APACHE II scores for different cutoff values were calculated using the receiver operating characteristic curve. Results Hospital mortality was 33.6%, which increased with co-morbidities (p = 0.03). A cutoff value for IAP of 23 mmHg was considered an optimal point predicting mortality. The IAP within the first 3 days for patients who died was higher than the cutoff value. For patients with IAP of 15 to 25 mmHg, nonsurgical therapy increased the rate of mortality (odds ratio 5.2, 95% confidence interval 1.0– 27.7; p = 0.03). Conclusions In patients with ACS emergency, it is recommended that decompressive laparotomy to be performed even if the IAP falls below 25 mmHg. For patients with IAP levels higher than 25 mmHg, the IAP should be meticolusly brought below the cutoff level during the postoperative period.

The abdominal compartment syndrome (ACS) is defined as increased intraabdominal pressure (IAP) resulting in multiorgan dysfunction including the cardiovascular, renal, splanchnic, musculoskeletal, and central nervous systems [1–3]. ACS can be seen following major trauma with profound shock, ileus, retroperitoneal hemorrhage, necrotizing pancreatitis, and gastrointestinal perforation [2, 4]. Identification of patients at risk, early recognition, and appropriately staged and timed intervention are key to effective management, as ACS has high morbidity and mortality rates [1, 3, 5]. This condition can be effectively



prevented and the mortality rate decreased by early diagnosis and preemptive intervention [2, 5]. The decision to decompress the elevated IAP surgically requires both clinical evaluation of the patient and the use of various diagnostic techniques [4–7]. However, ACS has a high rate of mortality despite primary decompression [8]. Several authors have attributed this to recurrent or persistent increased IAP [8]. Following decompression, a multidisciplinary approach to reconstruction of the open abdomen is commonly used [2, 5, 9]. In this study we evaluated (1) the decision to decompress according to the level of IAP during the early period of the disease and (2) analyzed any recurrent or persistent increase in IAP.

Materials and methods A prospective study was undertaken on adult patients at the Cukurova University School of Medicine, Adana, Turkey between January 1998 and January 2005. Patients aged [ 16 years with an intraabdominal pressure above 10 mmHg were included in the study. The study was approved by the medical ethics committee. Intraabdominal pressures were measured daily by obtaining the bladder pressure. Bladder pressures of 10 patients with a similar age distribution undergoing nonabdominal surgery were obtained (\5 mmHg) to calibrate the manometer and test the method of measurement. The bladder pressure measurement method was similar to that described by Kron et al. [10]. The patients were placed in supine position and their bladders emptied by means of a Foley catheter. The bladder was emptied, and the Foley catheter was clamped before each measurement. Normal saline (50 ml) was administered to the bladder via an 18-gauge needle that was inserted into the Foley catheter with a three-way stopcock. A manometer was attached to the stopcock, and measurements were taken relative to the symphysis pubis at the end of inspiration. The Foley catheter was clamped as far from the skin as possible to preserve sterility, as described by Burch et al. [11]. The age, sex, and co-morbid diseases of the patients were recorded. All patients were monitored via a central venous line, and vital signs and central venous pressures were recorded. Arterial blood gas values (pH, PO2, PCO2, O2 saturation, bicarbonate levels), blood urea nitrogen, creatinine clearance, and 24-hour urine volumes were obtained. The Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score and abbreviated mental test score were calculated to obtain acute confusion [12]. In addition, the etiologies of the the increased intraabdominal pressure were recorded. Major intraoperative and postoperative complications included emboli, leakage of anastomosis, bleeding,


World J Surg (2008) 32:13–19

myocardial infarcts, pneumonia, and adult respiratory distress syndrome. Minor complications, such as wound infection, were also evaluated. Deaths that occurred in hospital during the first 30 days have been accepted as the mortality rate. All patients had ‘‘primary ACS’’ according to the guidelines of the World Society of Abdominal Compartment Syndrome (WSACS) [13]. Patients with secondary and recurrent ACS were excluded. The patients were classified and graded according to their IAPs as described by Meldrum et al. [14]. The suggestions of Meldrum et al. [14] were taken as a guideline during the treatment of the patients. Grade 1 patients were treated with volume resuscitation, and only patients with critical conditions requiring emergency surgery (e.g., acute abdomen, hemorrhage, trauma) were taken to surgery. Laparatomy was performed via a midline incision, and all incisions were closed primarily. For grade 2 patients, hypervolemic resuscitation was performed; and only patients with a diagnostic indication for emergency surgery underwent surgery. In addition, patients with ACS having an IAP above 20 mmHg were operated on after common consensus of the general surgical team. Whereas the patients who had emergency surgery underwent primary abdominal closure, those who were operated on for ACS underwent temporary closure. In addition, all grade 3 and 4 patients underwent emergency laparotomy, and their operative wounds were closed using temporary methods.

Statistical analysis For each continuous variable, normality was checked by the Shapiro Wilks test and the Kolmogorof-Smirnov test. An appropriate nonparametric test was chosen for data that were not distributed normally. Univariate analysis was performed to assess the possible risk factors for mortality, including age, sex, IAP grade, and other clinical parameters. Categorical variables were analyzed by Pearson’s chi-squared test or Fisher’s exact test; continuous variables were analyzed by Student’s t-test or the Mann-Whitney U-test. Comparisons between IAP grades and the Apache II score and mental score were analyzed using the Kruskal Wallis test. Spearman’s correlation analysis was used to determine the relation of IAP with clinical parameters such as PO2, PCO2 , and SO2 among others. Receiver operating characteristic (ROC) analysis was used to identify the optimal cutoff values of IAP and Apache II for predicting mortality. The sensitivity and the specificity were calculated using SPSS statistical software version 12.0. Survival analyse was performed by Kaplan-Meier method and the curves were compared by the log-rank test. Cox proportional hazard regression model was

World J Surg (2008) 32:13–19


applied to identify multivariate predictors of survival. Age, APACHE II, treatment method, co-morbid disease, complications, and grade of the IAP were used as independent variables in the model. The results were expressed as the hazard ratio (HR) and adjusted odds ratio (OR) with a 95% confidence interval (CI). Data were presented as the number (%) or the mean ± SD and median interquartile range; p \ 0.05 considered statistically significant.

Results Of the total 119 patients, 68 were male and 51 were female, with a mean age of 55.8 ± 16.3 years (range 20–88 years). The etiologies were as follows: 35 (29.4%) acute abdomen, 29 (24.4%) abdominal trauma, 21 (17.6%) acute pancreatitis, 29 (24.4%) ileus. Altogether, 58 patients (49%) had comorbid conditions (29 cardiovascular diseases, 13 pulmonary diseases, 10 renal diseases, 6 other). The demographic findings and prognoses of patients are shown in Table 1. As the IAP increased, the respiratory rate, heart rate, central venous pressures, pPCO2, blood urea nitrogen (BUN), serum creatinine, and APACHE II scores increased, whereas PO2, O2 saturation, systolic and diastolic blood pressures, urine volume, creatinine clearance, and mental scores decreased (p \ 0.01 for all) (Table 2). The APACHE II scores were 13.6 ± 2.1 in grade 1; 19.5

Table 1 Clinical and demographic findings according to the prognosis


± 3.7 in grade 2; 27.0 ± 3.5 in grade 3; and 31.9 ± 3.2 in grade IV. The corresponding mental scores were 8.5 ± 1.0, 7.0 ± 1.1, 4.0 ± 1.2 and 2.8 ± 0.6, respectively (Fig. 1). The average APACHE II scores and the mental scores for all patients were 21.3 ± 7.1 and 6.1 ± 2.3, respectively. Hospital mortality was 33.6%, which increased with the presence of co-morbid conditions (p = 0.03). The mortality ratio was increasing with the IAP grade; it was 6.7% in grade I, 25.5% in grade II, 76.5% in grade III, and 75.5% in grade IV (p = 0.0001). There were two deaths (8.7%) in grade 1 patients who had nonsurgical treatment, whereas all of seven patients who underwent surgical treatment survived. However, this difference was not statistically significant (p = 0.4). In grade 2 patients, the mortality rate was found to be higher in those who had nonsurgical treatment. (OR 5.2, 95%CI 1.0–27.7, p = 0.03) (Table 3). The average IAP was 24.2 ± 9.8 in all patients at baseline. In grade 3 and 4 patients during the postoperative period, the average starting IAP was 24.2 ± 9.8, which dropped to 18.9 ± 9.8 on the second day. Throughout the first week, although there was a drop in IAP in all patients, the value was higher in patients who expired. For those who survived, the initial IAP was 20.2 ± 9.8 compared to 32.7 ± 9.2 in the ones who expired (p = 0.0001). The IAP was 27.2 ± 9.7 on the second day, 22.8 ± 10.0 on the third day, 15.2 ± 10.5 on the fourth day,

Prognosis Alive (no.)

Dead (no.)

Total no.


44 (64.7%)

24 (35.3%)

68 (57.1%)


35 (68.6%)

16 (31.4%)

51 (42.9%)


Co-morbidity No

46 (75.4%)

15 (24.6%)

61 (51.3%)


33 (56.9%)

25 (43.1%)*

58 (48.7%) 35 (29.4%)

Etiology Acute abdomen

28 (80.0%)

7 (20.0%)

Abdominal trauma

19 (65.5%)

10 (34.5%)

29 (24.4%)

Acute pancreatitis _ Ileus

14 (66.7%)

7 (33.3%)

21 (17.6%)

16 (55.2%)

13 (44.8%)

29 (24.4%)

2 (40.0%)

3 (60.0%)

5 (4.2%)


41 (59.4%)

28 (40.6%)

69 (58.0%)


38 (76.0%)

12 (24.0%)

50 (42.0%)


54 (63.5%)

31 (36.5%)

85 (71.4%)


25 (73.5%)

9 (26.5%)

34 (28.6%)


79 (66.4%)

40 (33.6%)

Others Treatment


* p \ 0.05 for presence or absence of co-morbidity




World J Surg (2008) 32:13–19

Table 2 Correlation between IAP and clinical parameters


Results are the mean ± SD RR: respiratory rate; TAS: tension arterial systolic; TAD: tension arterial diastolic; CVP: central venous pressure; BUN: blood urea nitrogen; CC: creatinine clearance; APACHE: Acute Physiology, Age, and Chronic Health Evaluation a Data expressed as median, with the interquartile range in parentheses, Mann-Whitney U-test



Spearman’s correlation with IAP

Age (years)

60.3 ± 16.8

53.5 ± 15.7*



7.2 ± 0.06

7.3 ± 0.06*



70.0 ± 12.5

82.4 ± 13.0*



49.5 ± 8.4

40.1 ± 11.8*



81.0 ± 7.5

88.5 ± 10.2*



16.2 ± 4.8

21.0 ± 5.4*



31.5 ± 5.4

24.5 ± 5.8*


128.9 ± 17.3

107.7 ± 16. 3*

0.59** -0.42**

Pulse TAS


80 (30)

100 (35)*


40 (36.2)

65 (20)*



18 (5) 47 (42)

12 (8)* 28 (19.5)*f

0.72** 0.62**

3.1 (2.2)

1.4 (1.4)*


Urine volume

225 (326.2)

977.5 (1500)*



9.7 (42.9)

74 (71)*


* p \ 0.05 between alive and dead groups

Mental scorea

3.5 (2)

8 (2.5)*



28.5 (9.2)

17 (9.5)*f


** Correlation is significant at the 0.01 level


34.5 (34)

19 (9.5) *

Creatininea a


Apache II

Table 3 Prognosis according to treatment method for each grade

Mental score





OR (CI) p

Grade I 30

Nonsurgical (n = 23) 2 (8.7%)

21 (91.3%) - (-) 0.4

Surgery (n = 7)

7 (100%)

Grade II 25

Nonsurgical (n = 27) 10 (37.0%) 17 (63.0%) Surgery (n = 20)

2 (10.0%)

18 (90.0%) 5.2 (1.0–27.7) 0.03

Nonsurgical (n = 0)

Surgery (n = 25)

13 (52.0%) 12 (48.0%) —

Grade III



Grade IV Nonsurgical (n = 0)


Surgery (n = 17)

13 (76.5%) 4 (23.5%)

OR: odds ratio; CI: confidence interval 5


-5 N=



Grade I



Grade II



Grade III



Grade IV

Fig. 1 Acute Physiology Age, and Chronic Health Evaluation (APACHE II) and mental score distribution according to grade

and 2.0 ± 4.8 on the seventh day for those who expired. These values were 15.3 ± 7.2, 10.6 ± 4.6, 6.2 ± 4.4, and


0.6 ± 1.1, respectively for patients who survived (p \ 0.05 for each time point except the last day) (Fig. 2). The sensitivity and specificity of IAP and Apache II scores for different cutoff values were calculated with the ROC curve. The ROC analysis showed that a cutoff IAP value of 23 mmHg and a value of 21 for the Apache II score were the optimal points predicting mortality (Fig. 3). The IAP within the first 3 days for patients who died was higher than the cutoff value of 23 mmHg determined by the ROC curve.

World J Surg (2008) 32:13–19



Error Bars show Mean +/- 1,0 SD

status alive ex

40,00 36,00

Table 4 Mean survival and Cumulative survival rates according to grade within the first 3 days Grade

Survival, mean (days)

Cumulative survival at day 3 (%)



6.9 (-)a




6.5 (7)




4.6 (4)* 3.0 (2)*

0.52 0.23

25/13 17/13


IAP mmHg

28,00 24,00 20,00 16,00



* p \ 0.05 grade I versus grade III and grade IV, log-rank test

Numbers in parentheses are the median values


p \ 0.05 grade II versus grade III and grade IV


p \ 0.05 grade III versus grade IV

0,00 -4,00





81, 33

81, 23




81, 8

81, 7

81, 5

Time (day) N=(a, e) 81, 38


Fig. 2 Intraabdominal pressure (IAP) values during the first 7 days: p \ 0.05 between alive and expired groups at each time point except the last day (Mann-Whitney U-test). Horizontal line represents the cutoff value of the IAP (23 mmHg)

The postoperative cumulative survival rate for the first 3 days were 96%, 82%, 52%, and 23% for grades I, II, III, and IV, respectively (p = 0.0001) (Table 4). The treatment method, IAP grade, complications, and APACHE II scores were found to be independent risk factors that increased the mortality rate according to Cox regression analyses (Table 5).


Sen: 0.80 Spe: 0.74 Criterion:>23




Reference Line APACHE II AUC=0.82


IAP AUC=0.85 0,00 0,00





1 - Specificity Fig. 3 Receiver operating characteristics (ROC) curves and cutoff values for IAP and APACHE II. AUC: area under the curve

Table 5 Results of Cox regression to determine survival within the first 7 days Parameter Age

HR with 95.0% CI


1.02 (0.99–1.04)



1.09 (0.99–1.19)


Treatment method (nonsurgical)

5.11 (1.11–23.66)


Co-morbid disease (yes)

1.27 (0.62–2.58)


Complication (yes)

0.43 (0.19–0.95)



2.98 (0.58–15.18) 17.47 (1.49–204.34)

0.187 0.023


22.55 (1.54–328.59)



HR: hazard ratio; CI: confidence interval

Discussion Abdominal compression syndrome is a challenging entity that is associated with high morbidity and mortality rates [11, 15]. There are two main problems during the course of the disease: survival of the patient during the early period and closure of the open wounds during the late period [15, 16]. This syndrome has a negative effect on cardiovascular, respiratory, renal, and mental functions. In many studies it was shown that the level of the IAP correlated with vital signs of the patient [7, 11, 14]. In our study, the IAP correlated with vital signs in addition to central venous pressure, PCO2, O2 saturation, urine volume, BUN, serum creatinine, creatinine clearance, and APACHE II score. Increased IAP alsocorrelated with a decrease in the mental score. The APACHE II score, which is used to determine the severity of the ACS [17–19], was found to be a factor that increased the mortality rate in our study. Recently, a new grading system has been proposed to classify ACS and to resolve any confusion in the nomenclature by WSACS [13]. Our study was done prospectively



between 1998 and 2005, which is before the new proposed grading; and we utilized the grading proposed by Meldrum et al. [14] as our guideline. However, our results also support the new grading system. For IAPs \ 15 mmHg (grade 1 according to both Meldrum et al. and WSACS), our treatment modality was the same as was proposed in the literature. For IAPs of 16 to 25 mmHg (grade 2 according to Meldrum et al./grade 2 and 3 according to WSACS), the suggestions of Meldrum et al. [14] have been proposed by many authors. However, for patients with established ACS, there are various parameters to be considered when making a decision about decompression. Whereas Meldrum et al. [14] performed decompression for IAPs of [25 mmHg, Eddy et al. [20] emphasized the importance of clinical parameters before undertaking an operation. Also, de Waele et al. [8], in a meta-analysis of data from 18 articles, reported that there was no consensus on the decision to operate. This difference in the treatment strategy arises especially for IAP levels between 16 and 25 mmHg. It is particularly true for patients with IAP levels between 16 and 25 mmHg. These patients should be evaluated, as a whole, by taking into consideration the IAP levels as well as the clinical condition. Experience is important in the decision making and treatment of such patients. For IAP levels between 16 and 25 mmHg, we performed hypervolemic resuscitation. Only patients with increased IAP requiring emergency surgery and those diagnosed as having clinical ACS underwent surgery. When we compared our results, those who had surgical treatment had a mortality of 10%, whereas those who underwent nonsurgical treatment had a mortality of 37%, with an increased risk of death (OR 5.2). The laparotomies of those patients who were operated on for emergency situations without ACS were closed primarily, whereas patients with ACS were subjected to temporary closure techniques. The mortality rate was higher than in the former group, but the difference did not reach statistical significance. During the postoperative period, the latter group of patients had a faster recovery and went on to have late definitive closure. Our ROC curve analysis showed that the optimal cutoff value for IAP may be 23 or 24 mmHg. At these cutoff values, the sensitivity (80% and 78%, respectively) and specificity (74% and 77%, respectively) indicate that the IAP is highly accurate in discriminating between the samples according to the mortality. Considering the seriousness of the disease, the cutoff value with the higher sensitivity (23 mmHg) is recommended as an optimal threshold that was supported by the other analyses. This cutoff value corresponds with grade 2 (according to Meldrum et al.), for which decompression is not recommended. We suggest that IAP levels between 16 and 25 mmHg should be followed


World J Surg (2008) 32:13–19

closely, and surgical treatment should be a strong option for patients with low IAP levels but clinically having signs of ACS. Because these patients have less edema at early stages than do those with higher grades, their wounds can be left open followed by late definitive closure after resolution of the visceral swelling. Our results are in concordance with the new grading system proposed by WSACS. Thus, we fully support the WSACS’s decision to bring grade 3 to between 20 and 25 mmHg. For IAP levels[25 mmHg (grades 3 and 4 according to Meldrum et al./grade 4 according to the WSACS), mortality is mostly seen during the operative or early postoperative period [5, 21]. Etiologies for the postoperative mortality may be multifactorial [8, 14, 15]. To investigate the etiology of the deaths, we analyzed the patients who died during the first week. Survival analysis showed that the survival rate was 82% among patients with grade 2 (IAP levels of 16–25 mmHg), 52% in grade 3 (IAP levels of 26–35 mmHg), and 23% in grade 4 (IAP levels[36 mmHg) at day 3. The mean survival was 4.6 days (median 4.0 days) for grade 3 and 3.0 days (median 2.0 days) for grade 4 patients. We suggest that because the mortality is highest during the first 3 days the IAP should be brought below a cutoff level during this period (23 mmHg for IAP). To do this, a revision of the temporary closure technique or reexploration laparotomy could be performed. De Waele et al. [8], in a metaanalysis of data generated between 1972 and 2004, used the terms recurrent or persistent ACS. In their article, only a study [17] group of four patients had postdecompression IAP levels of 26 mmHg, and mortality was 75%. Gracias et al. [22] reported the mortality of recurrent ACS to be 60%. However, there is still insufficient research on this subject. This brings up the question: Is the leading reason for high mortality recurrent or persistent ACS? We believe that there is a need for further prospective studies with data indicating rates of relaparotomy. The ACS is a condition associated with potentially high mortality that must be recognized early and managed effectively to optimize the outcome. Most deaths associated with ACS are due to sepsis or multiple organ failure. Death associated with this condition was reported in 10.6% to 68.0% of patients [10, 14, 20, 23]. There is a direct correlation between abdominal hypertension and mortality rates [11, 13, 15]. In our study, we found that mortality increased with increasing grade of disease. The mortality was 45.1% in patients with ACS, whereas it was 21% in patients with increased IAP alone. However, IAP is not the only factor determining survival [8, 23]. The presence of co-morbidity is a factor that increases mortality, which was also true for our patient population. We found that the primary etiology did not change the outcome and prognosis, which was mainly determined by the general clinical condition of the patient.

World J Surg (2008) 32:13–19

Conclusions At an IAP level 10 to 15 mmHg, the treatment should be nonsurgical. At an IAP level of 16 to 25 mmHg with ACS, emergency decompressive laparotomy should be performed. For IAP levels [ 25 mmHg, the IAP should be brought below a cutoff level during the postoperative period (23 mmHg for IAP).

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