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Intra-abdominal Hypertension and Colonic Hypoperfusion after Abdominal Aortic Aneurysm Repair
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Colonic ischaemia (CI), Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are devastating complications after abdominal aortic aneurysm (AAA) surgery. The aims of this thesis were to study the incidence and clinical consequences of IAH/ACS and the association between CI and intra-abdominal pressure (IAP) among patients undergoing OR for ruptured AAA (rAAA), to compare extraluminal pHi monitoring, with standard intra-luminal monitoring among patients operated on for AAA, and to study the frequency and clinical consequences of IAH/ACS after endovascular repair (EVAR) for rAAA.

The incidence of ACS was 26% in a retrospective study of 27 patients undergoing OR for rAAA. Consensus definitions on IAH/ACS were appropriate for patients after OR for rAAA: 78% (7/9) of patients with IAH grade III or IV developed organ failure and all patients who developed CI had some degree of IAH. Active fluid resuscitation treating hypovolaemia to avoid CI may partly cause IAH. The association between CI and IAP was investigated in a prospective study on 29 patients operated on for rAAA, 86% (25/29) were treated for hypovolaemia and ten (34%) had both IAH and CI. Since monitoring colonic perfusion is very important and there is no ideal method, a new technique, extraluminal colonic tonometry to detect colonic perfusion was compared with standard intraluminal tonometry. Although, this new method was not able to determine the severity of ischaemia it may serve as a screening test. EVAR of rAAA is feasible and patients may benefit from this less invasive procedure. Of 29 patients treated with this technique, 10% developed ACS, and all patients except one with preoperative shock developed some degree of IAH.

In conclusion, IAP/ACS is common after both OR and EVAR for rAAA, and is associated with adverse outcome. Monitoring IAP and colonic perfusion with timely intervention may improve outcome.

Place, publisher, year, edition, pages
Uppsala: Acta Unversitatis Upsaliensis , 2011. , 64 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 666
Keyword [en]
Abdominal aneurysm, Intra-abdomnial hypertension, Abdominal compartment syndrome, Colonic ischaemia, Colonic hypotension, Intra-abdominal pressure, rupture abdominal aortic aneurysm
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-149241ISBN: 978-91-554-8053-0OAI: oai:DiVA.org:uu-149241DiVA: diva2:408625
Public defence
2011-05-20, Universitetshuset sal IV, Övre Slottsgatan 2, 75105 Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2011-04-29 Created: 2011-03-16 Last updated: 2011-05-05Bibliographically approved
List of papers
1. Intra-abdominal hypertension and abdominal compartment syndrome following surgery for ruptured abdominal aortic aneurysm.
Open this publication in new window or tab >>Intra-abdominal hypertension and abdominal compartment syndrome following surgery for ruptured abdominal aortic aneurysm.
2006 (English)In: Eur J Vasc Endovasc Surg, ISSN 1078-5884, Vol. 31, no 6, 581-4 p.Article in journal (Refereed) Published
Abstract [en]

OBJECTIVES: To investigate the importance of intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS), based on the December 2004 consensus definition, on outcome after surgery for ruptured abdominal aortic aneurysm (rAAA). METHODS: Twenty-seven patients underwent open surgery for rAAA after the introduction of intra-abdominal pressure (IAP) measurements among patients at risk of IAH. Case-records were reviewed retrospectively. Seventeen patients underwent IAP-monitoring. RESULTS: Of eight patients with IAP <21 mmHg none developed colonic ischaemia or ACS. Of four patients with IAP 21-25 mmHg (IAH grade III), two underwent colonic resection. One patient treated with open abdomen died from cardiac arrhythmia. Five patients had IAP >25 mmHg (IAH grade IV). All developed ACS. Two were not decompressed and both developed pulmonary complications, one died. Two underwent colonic resection and one was treated with open abdomen, all three survived. Of 10 patients not monitored for IAP, one died of cardiac complications, but no patient developed signs of colonic ischaemia or ACS. Mortality at 30 days and 1 year was 3/27 (11%). CONCLUSION: IAH and ACS were common among patients undergoing surgery for rAAA. The ACS consensus definition seems appropriate in this clinical context. Monitoring IAP, and timely decompression of patients with IAH might improve outcome after surgery for rAAA.

Keyword
Abdomen/blood supply, Aged, Aneurysm; Ruptured/*surgery, Aortic Aneurysm; Abdominal/*surgery, Compartment Syndromes/*etiology, Consensus, Female, Humans, Hypertension/*etiology, Incidence, Male, Pilot Projects, Postoperative Complications, Retrospective Studies, Rupture; Spontaneous
Identifiers
urn:nbn:se:uu:diva-24385 (URN)16458547 (PubMedID)
Available from: 2007-04-16 Created: 2007-04-16 Last updated: 2011-05-05
2. Colonic ischaemia and intra-abdominal hypertension following open repair of ruptured abdominal aortic aneurysm
Open this publication in new window or tab >>Colonic ischaemia and intra-abdominal hypertension following open repair of ruptured abdominal aortic aneurysm
2009 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 96, no 6, 621-627 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND:: The aim was to investigate the association between colonic ischaemia and intra-abdominal pressure (IAP) after surgery for ruptured abdominal aortic aneurysm (rAAA). METHODS:: Sigmoid colon perfusion was monitored with an intramucosal pH (pHi) tonometer. Patients with a pHi of 7.1 or less were treated for suspected hypovolaemia with intravenous colloids and colonoscopy. IAP was measured every 4 h. Patients with an IAP of 20 mmHg or more had neuromuscular blockade, relaparotomy or both. RESULTS:: A total of 52 consecutive patients had open rAAA repair; 30-day mortality was 27 per cent. Eight patients died shortly after surgery. Fifteen were not monitored for practical reasons; mortality in this group was 33 per cent. IAP and pHi were measured throughout the stay in intensive care in the remaining 29 patients. Monitoring led to volume resuscitation in 25 patients, neuromuscular blockade in 16, colonoscopy in 19 and relaparotomy in two. One patient died in this group. Twenty-three of 29 patients had a pHi of 7.1 or less, of whom 15 had a pHi of 6.9 or less. Sixteen had an IAP of 20 mmHg or more, of whom ten also had a pHi below 6.90. Peak IAP values correlated with the simultaneously measured pHi (r = -0.39, P = 0.003). CONCLUSION:: Raised IAP is an important mechanism behind colonic hypoperfusion after rAAA repair. Monitoring IAP and timely intervention may improve outcome.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-103187 (URN)10.1002/bjs.6592 (DOI)000266647500009 ()19384909 (PubMedID)
Available from: 2009-05-15 Created: 2009-05-15 Last updated: 2013-08-14Bibliographically approved
3. A comparative study of extra- and intraluminal sigmoid colonic tonometry to detect colonic hypoperfusion after operation for abdominal aortic aneurysm
Open this publication in new window or tab >>A comparative study of extra- and intraluminal sigmoid colonic tonometry to detect colonic hypoperfusion after operation for abdominal aortic aneurysm
2011 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 42, no 3, 302-308 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: There is no ideal method to monitor colonic perfusion after abdominal aortic aneurysm (AAA) repair. The aim was to evaluate extraluminal sigmoid colon tonometry, comparing with the established intraluminal method.

Methods: Eighteen patients were monitored with both methods, 10 after elective and eight after ruptured AAA repair. One tonometric catheter was placed inside the sigmoid colon (intraluminal) and another extraluminally in close contact with the serosa of the sigmoid colon (extraluminal). Intra- and extraluminal partial pressure of carbon dioxide (pCO2) were measured every 10 min during 48 h postoperatively, 1536 simultaneous measurements. Intraluminal pH (pHi) and extraluminal pH (pHe) were calculated, and intra-abdominal pressure (IAP) was measured, every 4 h. Colonic ischaemia was defined as pHi ≤ 7.1.

Results: Mean pHi was 7.18 ± 0.11 and mean pHe was 7.28 ± 0.09. With a pHe cut-off value of ≤7.2, the sensitivity and specificity to detect colonic ischaemia were 95% and 95%, respectively. Accuracy was 95% and the positive and negative predictive values 0.80 and 0.99, respectively. The positive likelihood ratio was 19 and the negative likelihood ratio 0.05.

Conclusion: Extraluminal tonometry may serve as a screening test: A pHe-value <7.2 indicates suspected colonic ischaemia, meriting further investigation. It was not able to evaluate the severity of ischaemia.

Keyword
Tonometry, CO2 partial pressure, Colonic ischaemia, Abdominal aortic aneurysm, Rupture, Intra-abdominal pressure, Intra-abdominal hypertension
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-149614 (URN)10.1016/j.ejvs.2011.05.002 (DOI)000295061800006 ()
Available from: 2011-03-21 Created: 2011-03-21 Last updated: 2012-04-24Bibliographically approved
4. Intra-abdominal Hypertension and Abdominal Compartment Syndrome after Endovascular Repair of Ruptured Abdominal Aortic Aneurysm
Open this publication in new window or tab >>Intra-abdominal Hypertension and Abdominal Compartment Syndrome after Endovascular Repair of Ruptured Abdominal Aortic Aneurysm
2011 (English)In: European Journal of Vascular and Endovascular Surgery, ISSN 1078-5884, E-ISSN 1532-2165, Vol. 41, no 6, 742-747 p.Article in journal (Refereed) Published
Abstract [en]

Objectives: To investigate the frequency of intra-abdominal hypertension (IAH)and abdominal compartment syndrome (ACS) after endovascular repair (EVAR) of rupturedabdominal aortic aneurysm (rAAA).Methods: This was a prospective clinical study. Patients with endovascular repair of rAAAbetween April 2004 and May 2010 were included. Intra-abdominal pressure (IAP) was measuredin the bladder every 4 h. IAH and ACS were defined according to the World Society of theAbdominal Compartment Syndrome consensus document. Early conservative treatments(diuretics, colloids and neuromuscular blockade) were given to patients with IAP > 12 mmHg.Results: Twenty-nine patients, who underwent endovascular repair of a rAAA, had their IAPmonitored. Twenty-five percent of them were in shock at arrival. Postoperatively, 10/29(34%) patients had an IAP > 15 mmHg and six (21%) had an IAP > 20 mmHg. Three (3/29,10%) patients developed ACS that necessitated abdominal decompression in two. Five out ofsix patients with IAP > 20 mmHg presented with preoperative shock. All patients except onewith preoperative shock developed some degree of IAH.Conclusion: IAH and ACS are common and potential serious complications after EVAR for rAAA.Successful outcome depends on early recognition, early conservative treatment to reduce IAHand decompression laparotomy if ACS develops.

Keyword
Intra-abdominal pressure, Intra-abdominal hypertension, Abdominal compartment syndrome, Abdominal aortic aneurysm, Rupture, Endovascular repair
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-149613 (URN)doi:10.1016/j.ejvs.2011.02.021 (DOI)000291840900007 ()
Available from: 2011-03-21 Created: 2011-03-21 Last updated: 2012-05-11Bibliographically approved

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