Review for 10.1186/1471-230X-9-42 (2009)

Reviewer's report
Title:Intra-abdominal pressure alterations after large pancreatic pseudocyst
transcutaneous drainage
Version: 1Date:2 November 2008
Reviewer: Manu Malbrain
Reviewer's report:
I read with interest the paper by Theodossis et al. entitled “IAP alterations after
large pancreatic pseudocyst transcutaneous drainage”. The article is short and to
the point on a clinically relevant topic and what some even call a “sexy subject”.
However we have some comments.
The English is poor and sometimes gives the impression that the article was
written in a hurry. The text is also full of typographical errors. I suggest that the
manuscript should be substantially revised and rewritten by some-one who’s
native language is English. Otherwise I suggest that the authors have a look at
the following website: http://www.sfedit.net. It is of the up most importance that
the manuscript is edited professionally since some believe that "There is a clear
indication that badly written articles correlate with a high rejection rate."
Please use the correct definitions as recently published by the WSACS and also
update the correct references, the official definitions have been published in
Intensive Care Medicine [1-3]. According to these definitions IAH is defined by a
sustained or repeated pathologic elevation of IAP > 12 mmHg. (No APP criterion
here !); ACS is defined as a sustained IAP # 20 mmHg (with or without an APP <
60 mmHg) that is associated with new organ dysfunction / failure.
I would suggest to use mmHg instead of cmH2O to express IAP, since this is
more widely used. You can easily convert from cmH2O to mmHg by dividing by
the factor 1.36.
Update your reference list and refer to more recent papers also looking at
pancreatitis and CT guided evacuation of collections [4-11]. Also refer to recent
review papers on IAP measurement methods [12,13].
To play the devil’s advocate one could argue the meaning or rationale of this
study, why were the pancreatic pseudo cysts drained (caveat risk of infection),
since there was only a temporarily relief in IAP that returned to baseline values
after 7 days? What was the fluid balance? Was a control CT performed to check
refilling of pseudocysts or presence of hematoma or ascites formation, that could
have explained the increase in IAP?
In the method section: better define the signs of chronic and acute pancreatitis
that were checked for.
Results: please state the exact amount of fluids that were drained from the
pseudocysts – was this indeed around 1000 ml? Maybe it was more (or less) in
some patients. Based on what technique was the volume calculated on
admission/inclusion (on CT? please explain)
With regard to IAP measurement please state the zero reference point that was
used. Recent data show that this may substantially affect your IAP values
[14,15]. Please discuss. You have also stated that you instilled 50 ml into the
bladder prior to IAP measurement. Recent data however showed that instilling
50ml may increase intrinsic bladder pressure that then no longer reflects IAP
[16-19]. The World Society of Abdominal Compartment Syndrome
(www.wsacs.org) also advocate to instill a maximal amount of 20 ml into the
bladder [1]. Please discuss.
Please explain how IAP was measured – do you mean that at each tilme point 3
IAP measurements were performed and then the median was taken for analysis.
This median was then used for further analysis and the mean of the medians was
calculated and represented in the Figure, is this correct? Why did you not use the
mean of the 3 values?
In your reference list you refer to 3 articles in relation to obesity or high BMI (ref
6-8) however no data is provided whatsoever with regard to body antropomorphy
of the patients. Please describe better your patient population, add BMI (since a
recent multicenter also found that BMI was a predictor for IAH [20]). Also
calculate the abdominal wall compliance (Cabd): since you have the data for the
amount of volume evacuated as well as the delta IAP after evacuation you can
calculate Cabd = delta volume divided by delta IAP. This would be relevant and
new and unique information. Maybe IAP increased faster returning back to
baseline in the patients with a low Cabd???
Minor comments
Please expand all abbreviations when used for the first time and use them in a
concise way afterwards
Update reference list as suggested.
Figure 1: do not use smoothening of the interpolation line – just use a straight
line between the data points, add horizontal lines at the upper and lower error
bars (are these the SD?)
In conclusion: this is a very interesting small study, congratulations. Please take
into account the comments above.
References
1. Malbrain ML, Cheatham ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J,
Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K,
Johansson K, Kolkman K, Wilmer A: Results from the International Conference of
Experts on Intra-abdominal Hypertension and Abdominal Compartment
Syndrome. I. Definitions. Intensive Care Med 2006;32:1722-1732.
2. Cheatham ML, Malbrain ML, Kirkpatrick A, Sugrue M, Parr M, De Waele J,
Balogh Z, Leppaniemi A, Olvera C, Ivatury R, D'Amours S, Wendon J, Hillman K,
Johansson K, Kolkman K, Wilmer A: Results from the International Conference of
Experts on Intra-abdominal Hypertension and Abdominal Compartment
Syndrome. II. Recommendations. Intensive Care Med 2007;33:951-962.
3. Malbrain ML, De laet I, Cheatham M: Consensus conference definitions and
recommendations on intra-abdominal hypertension (IAH) and the abdominal
compartment syndrome (ACS)--the long road to the final publications, how did
we get there? Acta Clin Belg Suppl 2007;62:44-59.
4. Leppaniemi A, Johansson K, De Waele JJ: Abdominal compartment syndrome
and acute pancreatitis. Acta Clin Belg Suppl 2007;62:131-135.
5. Al-Bahrani AZ, Abid GH, Holt A, McCloy RF, Benson J, Eddleston J, Ammori
BJ: Clinical relevance of intra-abdominal hypertension in patients with severe
acute pancreatitis. Pancreas 2008;36:39-43.
6. Oda S, Hirasawa H, Shiga H, Matsuda K, Nakamura M, Watanabe E,
Moriguchi T: Management of intra-abdominal hypertension in patients with
severe acute pancreatitis with continuous hemodiafiltration using a polymethyl
methacrylate membrane hemofilter. Ther Apher Dial 2005;9:355-361.
7. De Waele JJ, Hoste E, Blot SI, Decruyenaere J, Colardyn F: Intra-abdominal
hypertension in patients with severe acute pancreatitis. Crit Care
2005;9:R452-457.
8. De Waele JJ, Hesse UJ: Life saving abdominal decompression in a patient
with severe acute pancreatitis. Acta Chir Belg 2005;105:96-98.
9. Reckard JM, Chung MH, Varma MK, Zagorski SM: Management of
intraabdominal hypertension by percutaneous catheter drainage. J Vasc Interv
Radiol 2005;16:1019-1021.
10. Gecelter G, Fahoum B, Gardezi S, Schein M: Abdominal compartment
syndrome in severe acute pancreatitis: an indication for a decompressing
laparotomy? 2002;19:402-404.
11. Pupelis G, Austrums E, Snippe K, Berzins M: Clinical significance of
increased intraabdominal pressure in severe acute pancreatitis. 2002;102:71-74.
12. Malbrain ML: Different techniques to measure intra-abdominal pressure
(IAP): time for a critical re-appraisal. Intensive Care Med 2004;30:357-371.
13. De Waele JJ, De laet I, Malbrain ML: Rational intraabdominal pressure
monitoring: how to do it? Acta Clin Belg Suppl 2007;62:16-25.
14. De Waele J, Cheatham ML, De Keulenaer B, Widder S, Kirkpatrick A,
Cresswell B, Malbrain ML, Bodnar Z, Meija J, Reis R, Parr M, Schulze R,
Compano S: The optimal zero reference transducer position for intra-abdominal
pressure measurement: a multicenter analysis. Acta Clin Belg Suppl
2007;62:247.
15. De Waele JJ, De Laet I, De Keulenaer B, Widder S, Kirkpatrick AW,
Cresswell AB, Malbrain M, Bodnar Z, Mejia-Mantilla JH, Reis R, Parr M, Schulze
R, Compano S, Cheatham M: The effect of different reference transducer
positions on intra-abdominal pressure measurement: a multicenter analysis.
Intensive Care Med 2008.
16. De laet I, Hoste E, De Waele JJ: Transvesical intra-abdominal pressure
measurement using minimal instillation volumes: how low can we go? Intensive
Care Med 2008;34:746-750.
17. De Waele J, Pletinckx P, Blot S, Hoste E: Saline volume in transvesical
intra-abdominal pressure measurement: enough is enough. Intensive Care Med
2006;32:455-459.
18. Malbrain ML, Deeren DH: Effect of bladder volume on measured intravesical
pressure: a prospective cohort study. Crit Care 2006;10:R98.
19. Chiumello D, Tallarini F, Chierichetti M, Polli F, Li Bassi G, Motta G, Azzari S,
Carsenzola C, Gattinoni L: The effect of different volumes and temperatures of
saline on the bladder pressure measurement in critically ill patients. Crit Care
2007;11:R82.
20. Malbrain ML, Chiumello D, Pelosi P, Wilmer A, Brienza N, Malcangi V, Bihari
D, Innes R, Cohen J, Singer P, Japiassu A, Kurtop E, De Keulenaer BL,
Daelemans R, Del Turco M, Cosimini P, Ranieri M, Jacquet L, Laterre PF,
Gattinoni L: Prevalence of intra-abdominal hypertension in critically ill patients: a
multicentre epidemiological study. Intensive Care Med 2004;30:822-829.
Level of interest: An article of importance in its field
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.
Declaration of competing interests:
I declare that I have stock options and a patent from a company (PMS) that
produces an IAP measurement device, however that is not specifically related to
the patient population and results from the above study