|Year : 2021 | Volume
| Issue : 1 | Page : 2-5
Peritoneal drainage as a safe alternative to laparotomy in children with abdominal compartment syndrome
Beatrix Hyemin Choi, Rivfka Shenoy, Dina Levy-Lambert, Jason C Fisher, Sandra S Tomita
Department of Surgery, Division of Pediatric Surgery, NYU School of Medicine, Hassenfeld Children’s Hospital at NYU Langone, New York, NY, USA
|Date of Submission||12-Jan-2021|
|Date of Decision||24-Feb-2021|
|Date of Acceptance||30-Mar-2021|
|Date of Web Publication||13-Jan-2022|
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Source of Support: None, Conflict of Interest: None
Context: Abdominal compartment syndrome in children carries a mortality of 40–60%. Although definitive treatment for this condition traditionally involves decompressive laparotomy, percutaneous catheter drainage of associated ascites is described as an alternative to laparotomy in adults. Aims: We explored the safety and efficacy of percutaneous catheter drainage of intraabdominal fluid for reversing abdominal compartment physiology in a critically-ill cohort of small children. Materials and Methods: We reviewed records of all children undergoing percutaneous catheter drainage for abdominal compartment syndrome from 2014 to 2018 in a single institution, excluding those who required drainage for other indications. Bedside sonogram-guided drainage using Seldinger technique or Penrose drain placement was performed by the pediatric surgical service, with drains removed on the resolution of compartment syndrome physiology and fluid output of <10 mL/day. Primary outcome measures were improvement in compartment physiology over 24 h. Statistical Analysis: Data were analyzed using descriptive statistics and paired Wilcoxon signed-rank tests. Statistical significance was assumed at P < 0.05. Results: Ten children ranging from 1.1 kg to 38 kg underwent 11 percutaneous catheter drainage procedures for abdominal compartment syndrome secondary to blood, serous fluid, air, or a combination. Significant physiologic improvement was seen across multiple variables including pulse rate, pH, and lactate. No patients later required decompressive laparotomy. Four patients died due to their primary disease. Conclusion: Percutaneous catheter drainage is safe and efficacious in reversing abdominal compartment physiology in children with intraabdominal fluid, and can be considered prior to surgical intervention when clinically appropriate.
Keywords: Abdominal compartment syndrome, abdominal decompression, ascites, intra-abdominal hypertension, paracentesis
|How to cite this article:|
Choi BH, Shenoy R, Levy-Lambert D, Fisher JC, Tomita SS. Peritoneal drainage as a safe alternative to laparotomy in children with abdominal compartment syndrome. Pediatr Respirol Crit Care Med 2021;5:2-5
|How to cite this URL:|
Choi BH, Shenoy R, Levy-Lambert D, Fisher JC, Tomita SS. Peritoneal drainage as a safe alternative to laparotomy in children with abdominal compartment syndrome. Pediatr Respirol Crit Care Med [serial online] 2021 [cited 2022 Jul 5];5:2-5. Available from: https://www.prccm.org/text.asp?2021/5/1/2/335732
| Introduction|| |
Abdominal compartment syndrome is a life-threatening condition in which intraabdominal hypertension causes organ dysfunction., This may develop after traumatic injuries that result in large intraabdominal bleeding or high-volume resuscitation related to abdominal surgery or sepsis., The treatment of abdominal compartment syndrome traditionally involved early decompressive laparotomy. Percutaneous catheter drainage has been used as an alternative in adults with massive ascites or hemoperitoneum as a presurgical intervention or a definitive treatment.,,, Although peritoneal drainage has long been used in the treatment of necrotizing enterocolitis in the neonate, its use in abdominal compartment syndrome in the pediatric population, specifically in infants and small children, has not been well described. We hypothesized that percutaneous catheter drainage is a safe approach for abdominal compartment syndrome in a population of infants and small children, and investigated its ability to reverse the physiology of abdominal compartment syndrome in small children with intraabdominal fluid.
| Materials and Methods|| |
We reviewed the records of all children 10 years of age or younger who underwent percutaneous catheter drainage for abdominal compartment syndrome physiology from January 1, 2014, to December 31, 2018, at Hassenfeld Children’s Hospital at NYU Langone Health. Abdominal compartment syndrome was identified in the medical records as respiratory distress requiring increasing ventilatory support, tense abdomen on physical examination, decreased urine output, and a metabolic acidosis component indicated by decreased blood pH and elevated blood lactate. Both bedside and operating room-based interventions were included in this study. Children undergoing percutaneous catheter drainage for indications other than abdominal compartment syndrome were excluded from the analysis. Procedures were equally distributed across a single academic pediatric surgical division comprised the same four surgeons throughout the study period, all of whom utilized a standardized technical approach. Sonogram-guided percutaneous drainage was performed using a Seldinger technique with catheter diameters ranging in size from five Fr to 12 Fr or a direct placement of a Penrose drain. Catheters were removed when abdominal compartment physiology resolved and output was <10 mL/day. The study was approved by the institutional review board.
Clinical variables selected for univariate descriptive analysis included age, weight, indication for catheter placement, length of time of catheter placement, and amount of fluid collected in the first 24 h. The primary outcome measures consisted of changes to physiologic variables representative of abdominal compartment syndrome severity before and after drain placement, including heart rate, urine output, FiO2, SpO2, pH, pCO2, pO2, and blood urea nitrogen. Prior to comparative analyses, continuous variables were individually evaluated for distribution normality using a Shapiro-–Wilk statistic and normality plots to guide nonparametric testing. Outcome variables were compared using paired Wilcoxon signed-rank tests. Results containing continuous variables are presented as median values with interquartile ranges unless otherwise noted. Statistical significance was accepted for P < 0.05. Data analyses were performed using the IBM Statistical Package for the Social Sciences (IBM SPSS 25.0, Armonk, New York, USA).
| Results|| |
We identified 46 children who underwent percutaneous peritoneal drainage over the 5-year study period and excluded 36 from the analysis because their drainage procedure was not related to abdominal compartment syndrome concerns. Most of these 36 excluded patients had drains placed for necrotizing enterocolitis. Of the remaining ten children who qualified for analysis, we identified 11 percutaneous catheter drainage interventions; one child underwent two discrete drainage interventions spaced 6 months apart for recurrent malignant ascites driving compartment physiology. Of note, over the study period, no children with abdominal compartment syndrome underwent decompressive laparotomy. Demographics and indications for percutaneous catheter drainage for the study sample are summarized in [Table 1]. The cohort was largely comprised infants and small children: ages ranged from 2 days to 7 years, including seven patients under 6 weeks of age. Drainage catheters remained in place from 1 day to 35 days. The amount of fluid drained in the first 24 h following percutaneous catheter placement ranged from one to over 600 cc/kg.
|Table 1: Clinical characteristics of patients undergoing peritoneal catheter drainage, original|
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[Table 2] summarizes the physiologic response across the cohort following percutaneous catheter drainage, as measured by multiple objective parameters immediately before and 24 h after drainage. We observed improvement in all measured physiologic variables, with statistically significant improvements identified for pulse, SpO2, pH, pCO2, pO2, and lactate. No complications directly related to catheter occurred throughout the study period. While there were no procedure-related mortalities, four of the ten children in the study (30%) ultimately expired. Three of the deaths occurred within days after catheter placement in patients with congenital diaphragmatic hernia who succumbed to complications secondary to severe persistent pulmonary hypertension. One death occurred within 30 days of catheter placement in a patient with severe complications from acute megakaryocytic leukemia. Two children (Cases 6 and 7) had drainage consisting largely of air with trace intraabdominal fluid. While one (Case 6) experienced rapid improvement postpercutaneous catheter drainage of intraabdominal air, the other (Case 7) expired soon after the procedure secondary to the progression of his primary disease process.
|Table 2: Physiologic parameters before and after peritoneal catheter drainage, original|
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| Discussion|| |
Abdominal compartment syndrome is an increasingly recognized morbidity affecting critically ill pediatric patients. Intraabdominal hypertension can lead to end-organ dysfunction in abdominal compartment syndrome through compression of the inferior vena cava and splanchnic vasculature. This subsequently impedes venous return to the heart, impairs cardiac output with disruption of systemic perfusion, and compromises renal function. The end result is progression to multisystem organ failure and death. The traditional use of early decompressive laparotomy and supportive care to lower intraabdominal hypertension and maintain adequate abdominal perfusion pressure carries significant risk of complications including infection, hemorrhage, and abdominal wall hernias. Furthermore, asystolic cardiac arrest has been noted in up to 25% of patients treated with decompressive laparotomy, believed to be induced by a reperfusion effect that triggers release of postischemic intracellular contents.,,
Peritoneal catheter drainage can effectively lower intraabdominal pressure with less morbidity than laparotomy, and has been described in adults.,,, While no catheter-related complications occurred in this series, image-guided percutaneous drainage of intraabdominal fluid can be complicated by bleeding, bowel perforation, and bacterial peritonitis as noted by studies done in the radiology literature., In a pilot study done on adult burn patients, percutaneous decompression was used in nine patients with abdominal compartment syndrome, relieving the intraabdominal hypertension in five successfully with four requiring laparotomy; no complications of percutaneous drainage were noted.
While peritoneal drainage is accepted therapy for neonates with intestinal perforation such as in necrotizing enterocolitis, its use in abdominal compartment syndrome in the pediatric population has not been as well described. Isolated case reports have described the successful use of peritoneal drainage for emergent decompression of abdominal compartment syndrome in infants with septic shock and severe burns, and in older children after blunt trauma.,,, One retrospective series of percutaneous catheter drainage in 12 children with a median age of 3 years demonstrated reduction in intraabdominal hypertension and improvement in physiologic parameters. Our study similarly showed a significant decrease in intraabdominal hypertension but in a much younger cohort. Like our study in which 30% of our patients died, this retrospective series had a similar mortality rate of 25%. In our study, the deaths were not catheter related, but reflected the often severe underlying conditions that lead to abdominal compartment syndrome.
In this study, we analyzed the records of children undergoing peritoneal catheter drainage for abdominal compartment syndrome secondary to ascites, hemoperitoneum, and pneumoperitoneum with ascites. We found that peritoneal drainage in these children resulted in significant physiologic improvement with no catheter-related complications. We demonstrated the safety and effectiveness of this approach in our patient population, and suggest it continue to be studied as a therapy for abdominal compartment syndrome in the pediatric population.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]