Discussion
According to WSACS definitions, primary ACS (formerly termed as surgical, postoperative, or abdominal ACS) is characterized by the presence of acute, or subacute IAH, of relatively brief duration. Such duration occurs as a result of an intra-abdominal reason such as: abdominal trauma, ruptured abdominal aortic aneurysm, hemoperitoneum, acute pancreatitis, secondary peritonitis, retroperitoneal hemorrhage, or liver transplantation. Fluid extravasations after hip arthroscopy also can lead to ACS. This potentially lethal complication of hip arthroscopy highlights the need for orthopedists to be aware of this rare but serious complication, and of the steps needed to be undertaken in order to manage it promptly. Although Fowler and Owens mention death after hip arthroscopy among Bartlett's patients, Bartlett et al. do not confirm such information in their original paper. The prevalence and etiological factors for IAH and ACS after hip arthroscopy are being reviewed.
Evidence-based medicine treatment guidelines have been presented to facilitate the diagnosis and management of IAH and ACS (Figure 1). The choice (and success) of the medical management strategies given in Figure 1 is strongly related to both the etymology of the patient's IAH/ACS, and the patient's clinical situation. The appropriateness of each intervention should always be considered prior to implementing these interventions in any individual patient. This paper presents the case of ACS after hip arthroscopy, treated successfully with paracentesis and percutaneous catheter decompression. The pathophysiology of IAH and ACS in hip arthroscopy has been described in many papers. The details have been collected in Table 1 and Table 2 . Many authors have suggested the only possible way for the irrigation fluid to flow is by a retroperitoneal course along the iliopsoas muscle and the iliac vessels with intraperitoneal perforation along their course. The proposed mechanism of extravasation is similar to our case. After having performed an analysis of all the cases described in the literature, and having collected data from our case, we were unable to indicate any clear risk factors of IAH and ACS in hip arthroscopy. In contrast to other authors' suggestions, a prolonged surgical time (95 – 165min in analyzed cases), and patient's position (four cases in supine positions and three cases in lateral positions) or specific surgical procedures such as extra-articular surgery (many types of surgical procedures), we could define no clear risk factors of IAH or ACS. We agree with Verma and Sekiya, and hypothesize that our patient had had communication between the retroperitoneal and peritoneal cavity, which allowed for this amount of fluid extravasation. This hypothesis is also supported by nephrologists' experience with acute ultrafiltration failure (AUFF), which is an important clinical problem among patients having peritoneal dialysis (PD). Lam et al. reported the cases of three patients on continuous ambulatory PD who developed reversible ultrafiltration failure secondary to retroperitoneal leakage (RPL). Lam et al. also reported that during the 5-year study period, 36 patients in a cohort of 743 patients on maintenance PD developed AUFF. Of these 36 patients, 23 were found to have RPL, which was confirmed by either computed tomography (n=16) or magnetic resonance imaging (n=7). The authors concluded that RPL was not uncommon among patients with AUFF. There is a high possibility for the occurrence of RPL among patients with AUFF and additionally having a history of hernia or pleuroperitoneal communication. In addition, the commonly used high-flow pump for hip arthroscopy can pump fluid with a maximum flow rate of 1.5L/minute; the catheter for PD can transmit fluid with a maximum flow of 0.5L/minute and would fill up the abdomen with 2L of fluid in 5 to 10 minutes. This means that even 2 to 3 minutes of surgery without abdomen examinations may be sufficient to overlook dangerous abdominal extravasation.
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Figure 1.
Intra-abdominal hypertension/intra-abdominal compartment syndrome management algorithm.
In our opinion, hip arthroscopy per se, places the patient at high risk for primary ACS. Intra-abdominal fluid extravasation is a known complication (0.16% incidence) of hip arthroscopy which needs to be informed to the patient prior to the procedure.
The indication of risk factors of IAH and ACS in hip arthroscopy needs further research on a larger scale of cases. It appears that patients with a history of hernia or pleuroperitoneal communication are more likely to be classified as at higher risk of ACS before hip arthroscopy. However, complications are very rare, and because of that we recommend to collect all cases in a WSACS database, or precisely describe the cases in medical papers. This should allow us to collect a larger amount of data for further analysis. The primary mission of WSACS is to promote research, foster education, and improve the survival rate of patients with IAH and ACS, by sharing information on effective management strategies. The WSACS provides instructional materials (IAH and ACS consensus definitions and clinical practice guidelines) to upgrade the education of physicians, nurses, respiratory therapists, and other healthcare providers. WSACS has recently published two consensus documents detailing the current state-of-the-art diagnosis and management of IAH/ACS. No single management strategy can be uniformly applied to a patient with IAH/ACS. Several fundamental management concepts, however, remain appropriate across all cases. While surgical decompression is commonly considered the only treatment for IAH/ACS, nonoperative medical management strategies are now recognized as playing a vital role in both the prevention and treatment of organ dysfunction and failure due to elevated intra-abdominal pressure (IAP). Appropriate treatment and management of IAH and/or ACS is based upon four general principles: (a) serial monitoring, (b) optimization of systemic perfusion and a patient's organ function with elevated IAP, (c) institution of specific medical procedures (with paracentesis and percutaneous catheter decompression as a main point of treatment) to reduce IAP and the end-organ consequences of IAH/ACS, and (d) prompt surgical decompression for refractory IAH. An algorithm for the management of a patient with IAH/ACS has been proposed in Table 3 .
Among patients having undergone trauma or elective surgery, operative decompression is advocated if noninvasive treatment options prove insufficient. Decompression laparotomy reduces IAP instantaneously and is often a life-saving procedure. Given the morbidity of open abdominal decompression, less invasive means to reduce IAP would certainly be appealing. Percutaneous catheter decompression represents a less invasive method for treating IAH or primary ACS due to free intra-abdominal fluid. This technique appears to be effective in reducing IAP, and potentially corrects the IAH-induced organ dysfunction. Possible performance under ultrasound, or computed tomography guidance and percutaneous decompression among appropriate patients, appears to be effective in solving IAH/ACS and avoiding the need for surgical decompression. In light of the potential benefits of avoiding abdominal decompression, we suggest that percutaneous catheter decompression should be considered among patients with intraperitoneal fluid or blood, who demonstrate symptomatic IAH or ACS.