Bressan Alexsander K, Kirkpatrick Andrew W, Ball Chad G
Department of Surgery, University of Calgary and the Foothills Medical Centre, North Tower 10th Floor, 1403-29th Street Northwest, Calgary, AB, T2N 2T9, Canada.
Departments of Surgery and Oncology, Foothills Medical Centre and the University of Calgary, 1403 - 29 Street NW, Calgary, AB, T2N 2T9, Canada.
J Med Case Rep. 2016 Sep 15;10(1):251. doi: 10.1186/s13256-016-1045-x.
Postoperative hemorrhage is a significant cause of morbidity and mortality following liver resection. It typically presents early within the postoperative period, and conservative management is possible in the majority of cases. We present a case of late post-hepatectomy hemorrhage associated with overt abdominal compartment syndrome resulting from a localized functional compartment within the abdomen.
A 68-year-old white man was readmitted with sudden onset of upper abdominal pain, vomiting, and hemodynamic instability 8 days after an uneventful hepatic resection for metachronous colon cancer metastasis. A frozen abdomen with adhesions due to complicated previous abdominal surgeries was encountered at the first intervention, but the surgery itself and initial recovery were otherwise unremarkable. Prompt response to fluid resuscitation at admission was followed by a computed tomography of his abdomen that revealed active arterial hemorrhage in the liver resection site and hemoperitoneum (estimated volume <2 L). Selective arteriography successfully identified and embolized a small bleeding branch of his right hepatic artery. He remained hemodynamically stable, but eventually developed overt abdominal compartment syndrome. Surgical exploration confirmed a small volume of ascites and blood clots (1.2 L) under significant pressure in his supramesocolic region, restricted by his frozen lower abdomen, which we evacuated. Dramatic improvement in his ventilatory pressure was immediate. His abdomen was left open and a negative pressure device was placed for temporary abdominal closure. The fascia was formally closed after 48 hours. He was discharged home at postoperative day 6.
Intra-abdominal pressure and radiologic findings of intra-abdominal hemorrhage should be carefully interpreted in patients with extensive intra-abdominal adhesions. A high index of suspicion and detailed understanding of abdominal compartment mechanics are paramount for the timely diagnosis of abdominal compartment syndrome in these patients. Clinicians should be aware that abnormal anatomy (such as adhesions) coupled with localized pathophysiology (such as hemorrhage) can create a so-named abdominal intra-compartment syndrome requiring extra vigilance to diagnose.
术后出血是肝切除术后发病和死亡的重要原因。它通常在术后早期出现，大多数情况下可行保守治疗。我们报告一例肝切除术后晚期出血病例，该出血与因腹部局部功能腔隙导致的明显腹腔间隔室综合征相关。
一名68岁白人男性在因异时性结肠癌转移行肝切除术后8天，因突发上腹痛、呕吐和血流动力学不稳定再次入院。首次干预时发现腹部因既往复杂腹部手术导致粘连呈冰冻状，但手术本身及初期恢复情况并无异常。入院时对液体复苏反应迅速，随后腹部计算机断层扫描显示肝切除部位有活动性动脉出血及腹腔积血（估计量<2L）。选择性动脉造影成功识别并栓塞了其右肝动脉的一个小出血分支。他的血流动力学保持稳定，但最终发展为明显的腹腔间隔室综合征。手术探查证实其结肠上区在显著压力下有少量腹水和血凝块（1.2L），受冰冻状下腹部限制，我们将其清除。通气压力立即显著改善。腹部敞开，放置负压装置进行临时腹壁关闭。48小时后正式关闭筋膜。术后第6天他出院回家。
对于有广泛腹腔粘连的患者，应仔细解读腹腔内压力及腹腔内出血的影像学表现。高度的怀疑指数以及对腹腔间隔室力学的详细了解对于这些患者及时诊断腹腔间隔室综合征至关重要。临床医生应意识到异常解剖结构（如粘连）与局部病理生理状态（如出血）相结合可导致所谓的腹腔内间隔室综合征，需要格外警惕以进行诊断。
