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Wed Sep 12 14:40:42 BST 2007

I agree with the distinction between ACS and IAH.  I've seen
(particularly in the morbidly obese) higher bladder pressures without
end-organ dysfunction. Regardless of your intra-abdominal pressure, if
the patient is still ventilating/oxygenating and adequately perfusing
splanchnic bed, kidneys, etc, how will you improve their physiologic
status with an incision?
I was involved with an extensive review of this literature a year or so
ago, and there aren't any studies specifically addressing the amount of
suction and its variable effects. Fistula rates were always associated
with destructive bowel injuries, anastamoses, etc. The only approaches
to reduce fistula rates weren't anything surprising-protecting
anastamoses with available omentum, handling the edematous bowel as
little as possible with take-backs and washouts. Regardless, I wouldn't
put suction on a fistula, and I doubt anyone wants to study it. Would be
interested to hear other comments.
John Green, MD

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