Permissive Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction

Sir: The Abdominal Compartment Society applauds the Case Medical Centre group for their leadership in studying abdominal wall reconstruction surgery and perioperative care. Our comments regarding “Permissive Intraabdominal Hypertension following Complex Abdominal Wall Reconstruction”1 were commissioned and supported by the recently renamed World Society of the Abdominal Compartment Syndrome, which is now called “WSACS - Abdominal Compartment Society.” Our Society was renamed to reflect a greater appreciation of the importance of the abdominal compartment itself as an entity as overt abdominal compartment syndrome becomes less common in practice.2 However, intraabdominal hypertension remains nearly ubiquitous and poorly understood in all areas of practice. Petro and colleagues recently confirmed their earlier retrospective observations that mild (average grade II) intraabdominal hypertension typically resolved by the first postoperative day in patients undergoing abdominal wall reconstruction with myofascial release without major postoperative complications.3 They hypothesized that releasing the transversus abdominis muscle may allow compartment stretching and advocated accepting intraabdominal hypertension and considering it “permissive” in this setting of abdominal wall reconstruction. This finding presumably reflects on their careful patient selection and meticulous surgical technique. However, the intraabdominal hypertension in question was on average modest (18.2 mmHg), constituting grade II intraabdominal hypertension.4 Therefore, one statement made by the authors that should be understood in context is the assertion that the World Society of the Abdominal Compartment Society–recommended therapy for abdominal compartment syndrome is to “perform/revise abdominal decompression with temporary abdominal closure.”4 Although the Society does advocate prompt and definitive intervention in cases of overt abdominal compartment syndrome with clear organ failure (a highly lethal condition), the revised 2013 guidelines have tried to emphasize a number of medical and less invasive options to manage intraabdominal hypertension, which is graded from I to IV.4 For grade II intraabdominal hypertension, there are many recommended nonsurgical therapies, of which judicious/restrictive fluid management is among the options.4 Furthermore, it is being increasingly recognized that subtle degrees of intraabdominal hypertension may have profound although sometimes initially unapparent effects on physiology.5 Thus, we again applaud the authors for their caution in considering changes in ventilatory plateau pressures as a reflection of potential early organ failure, which in association with a sustained intraabdominal pressure greater than 20 mmHg might technically constitute formal abdominal compartment syndrome. The definition of abdominal compartment syndrome in the guidelines thus requires more than one measurement above 20 mmHg. However, considering a discretionary therapy, mechanical ventilation, as an outcome effect is realistically not sufficient to designate these cases as abdominal compartment syndrome without further data on end-organ function. The increase in alveolar pressures merely results from pressure transmission within the concept of the polycompartment model and by no means reflects abdominal compartment syndrome. Thus, we submit that the “permissive” tolerance of mild to modest intraabdominal hypertension in the setting of large elective ventral hernia repair with myofascial release that the authors recommend is completely congruent with the Abdominal Compartment Society guidelines to optimally manage intraabdominal hypertension with noninvasive therapies if life-threatening organ failure does not ensue. Similar intraabdominal pressure values in different patients may have different effects on the course of illness and outcome requiring different management. Much depends on the duration and dynamics of intraabdominal hypertension and whether the increase in intraabdominal pressure was a result of increased intraabdominal volume or decreased compliance of the abdominal wall.6 We would thus simply add the caveat that any patient with intraabdominal hypertension should be closely followed with ongoing intraabdominal pressure monitoring and receive appropriately escalating therapies to ameliorate intraabdominal hypertension if detected.4 Finally, although the most recent Abdominal Compartment Society guidelines were written with the best available evidence, this was often limited in volume and quality. Thus, the Abdominal Compartment Society looks forward to incorporating valid ongoing data into future updates to these “real-time” management guidelines. The authors correctly noted that most attention to intraabdominal hypertension/abdominal compartment syndrome has been in critically ill/injured patients, who typically are proinflammatory and at risk of permeability disorders leading to edema. The authors have suggested that intraabdominal hypertension in patient cohorts without these factors may pose less risk of subsequent harm. This is an important question that illustrates how further study is urgently required in many cohorts of non–critically ill/injured adult patients. The authors are strongly encouraged to continue their studies and are invited to collaborate with the Abdominal Compartment Society to continue to lead the search for the best care for those undergoing major reconstruction of their abdominal compartment. APPENDIX The complete Executive Committee of the WSACS–Abdominal Compartment Society comprises the following individuals: Andrew W. Kirkpatrick, M.D., M.H.Sc.; Jan De Waele, M.D., Ph.D.; Annika Reintam Blaser, M.D., Ph.D.; Manu L. N. G. Malbrain, M.D., Ph.D.; Martin Bjorck, M.D., Ph.D.; Ari Leppaniemi, M.D., Ph.D.; Janeth C. Ejike, M.D.; Michael Sugrue, M.D.; Inneke De Laet, M.D.; Stefan Acosta, M.D.; Rao Ivatury, M.D.; Bart De Keulenaer, M.D.; Zsolt J. Balogh, M.D., Ph.D.; Scott D’Amours, M.D.; Bruno M. Pereira, M.D.; and Mark Kaplan, M.D. ACKNOWLEDGMENT This communication was commissioned and supported by the WSACS–Abdominal Compartment Society (www.wsacs.org). DISCLOSURE All of the authors are executive members of the Abdominal Compartment Society. None of the authors has a direct financial interest in any of the products, devices, or drugs mentioned in this communication. Andrew W. Kirkpatrick, M.D., M.H.Sc.Regional Trauma ServicesFoothills Medical CentreCalgary, Alberta, Canada Derek J. Roberts, M.D., Ph.D.Department of SurgeryUniversity of CalgaryCalgary, Alberta, Canada Jan De Waele, M.D., Ph.D.Department of Critical Care MedicineGhent University Hospital and Ghent Medical SchoolGhent, Belgium Annika Reintam Blaser, M.D., Ph.D.Clinic of Anaesthesiology and Intensive CareUniversity of TartuTartu, Estonia Manu L. N. G. Malbrain, M.D., Ph.D.ICU and High Care Burn UnitZNA StuivenbergAntwerpen, Belgium Martin Bjorck, M.D., Ph.D.Department of Surgical SciencesUppsala UniversityUppsala, Sweden Zsolt J. Balogh, M.D., Ph.D.University of NewcastleJohn Hunter HospitalNewcastle, New South Wales, Australiafor the Executive Committee of the WSACS - AbdominalCompartment Society

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