Pediatr Surg Int (2011) 27:399–405

DOI 10.1007/s00383-010-2808-x

ORIGINAL ARTICLE

Abdominal compartment syndrome in childhood: diagnostics,

therapy and survival rate
Gerhard Steinau • Torsten Kaussen •
Beate Bolten • Alexander Schachtrupp •
Ulf P. Neumann • Joachim Conze • Gabriele Boehm

Accepted: 10 November 2010 / Published online: 5 December 2010

! Springer-Verlag 2010

Abstract remaining six cases (21.4%) was sepsis with multiorgan

Purpose The abdominal compartment syndrome (ACS) in
childhood is a rare but dire disease if diagnosed delayed and
treated improperly. The mortality amounts up to 60% (Beck
et al. in Pediatr Crit Care Med 2:51–56, 2001). ACS is defined
by a sustained rise of the intraabdominal pressure (IAP)
together with newly developed organ dysfunction. The pres-
ent study reports on 28 children with ACS to evaluate its
potential role in the diagnosis, treatment and outcome of ACS.
Methods Retrospectively, medical reports and outcome
of 28 children were evaluated who underwent surgical
treatment for ACS. The diagnosis of ACS was established
by clinical signs, intravesical pressure-measurements and
concurrent organ dysfunction.
Results Primary ACS was found in 25 children (89.3%)
predominantly resulting from polytrauma and peritonitis.
Three children presented secondary ACS with sepsis (2
cases) and combustion (1 case) being the underlying
causative diseases. Therapy of choice was the decom-
pression of the abdominal cavity with implantation of an
absorbable Vicryl" mesh. In 18 cases the abdominal cavity
could be closed later, while in the other ten cases granu-
lation of the mesh was allowed. The overall survival rate
was 78.6% (22 of 28 children). The cause of death in the
G. Steinau (&) ! B. Bolten ! A. Schachtrupp !
U. P. Neumann ! J. Conze ! G. Boehm
Department of Surgery,
University Hospital Aachen, Aachen, Germany
e-mail: gsteinau@ukaachen.de
J. Conze
e-mail: jconze@ukaachen.de
T. Kaussen
Department of Pediatrics,
Dritter Orden Passau, Passau, Germany
failure.
Conclusion Our results suggest that early establishment
of the specific diagnosis of ACS followed by swift therapy
with reduction of intraabdominal hypertension is essential
in order to further reduce the high mortality rate associated
with this condition.
Keywords Abdominal compartment syndrome !
Diagnostics ! Therapy ! Survival rate ! Children
Introduction
The abdominal compartment syndrome (ACS) is rare in
childhood and presents a life-threatening entity with a
lethality of up to 60% [1]. The presence of inverse pressure
ratios between thoracic and abdominal cavity was first
described by Marey in 1864 published by Light [2]. ACS is
defined by a pathological increase of the intraabdominal
pressure (IAP) [3] with consecutive dysfunction of one or
several organ systems leading to adverse hemodynamic,
respiratory and renal effects [4]. Referring to the WSACS
definitions (http://www.WSACS.org), primary, secondary
and tertiary ACS are distinguished. Specific diagnostic
means and immediate therapeutic intervention are neces-
sary to reduce the IAP.
Materials and methods
In this retrospective study the medical records of all chil-
dren with diagnosis ACS (age under 18 years) between
1998 and 2008 were examined. 28 children were identified
and enclosed.

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Statistics Prematurity and gestational age

The statistical evaluation was done using the statistical
software programme SAS. To the estimate of dimensions
considering the censored data the LIFETEST routine
integrated in SAS was used. As a product limit assessor the
method of Kaplan–Meier found use.
By definition, prematurity means birth before completion
of 37th week of gestation (WOG). Within the age groups of
the newborns and infants 3 (37.5%) of the children had
been born before the 37th WOG. The most premature
newborn was born in the 23rd ? 3 WOG and the most
mature newborn during the 37th WOG.

Results Malformations and genetic disorders

Age distribution Medical histories of 26 (92.9%) delivered information about

the presence or absence of concomitant malformations or
The study group consisted of 28 children and was divided genetic disorders. 14 children (53.8%) showed none, and the
into four sub-groups dependent on their age (newborn, other 12 children (46.2%) at least one malformation or
babies, toddler and school children). Despite the newborn genetic disorder. With regard to the last-mentioned children,
life period lasts as short as 30 days postnatal, 10.7% of all 6 children (50%) had only one, 3 children (25%) two, and 3
investigated children belonged to the newborn group (3 of children (25%) three malformations or genetic disorders,
28 children; aged 19.2 days). As underlying cause in all respectively. An overview shows (Table 1).
these children necrotizing enterocolitis (NEC) was diag-
nosed. The group of babies (2–12th life month) comprised Diagnostics
five children (17.9%; aged 3.0 ± 1.2 months) suffered
from NEC, peritonitis, intestinal perforation and ileus as Within the first years of the above-mentioned observational
ACS-inducing entities. The toddlers (2nd–6th year) pre- period, the diagnosis of an ACS was made exclusively by
sented the smallest group of two children (7.1%, aged
28.5 ± 0.7 months), in which combustion and polytrauma Table 1 Number of malformations, respectively, genetical diseases
had led to ACS. The strongest group was the school chil-
Genetic disorder Frequency
dren (7th–18th year) with 18 (64.3%) children. The mean
age of this group was 12.9 (±3.6) years. Polytrauma, Cerebral
peritonitis, pancreatitis and intraabdominal bleeding had Meningomyelocele 1
led to the ACS (Fig. 1). Arnold-Chiari syndrome 1
Mental retardation of unknown cause 1
Gender distribution Pulmonary
Unilateral lung hypoplasia 1
The over-all gender distribution was even with 14 girls Cardiac
(50.0%) and 14 boys (50.0%). Within the age group of Persistent ductus botalli 3
newborns the female children with 66.7% were outbal- Ventricular septal defect 1
ancing the male (33.3%). Within the other age groups the Morbus fallot 1
female-to-male ratio was nearly even. Diaphragm
Unilateral diaphragmatic agenesia 1
Gastrointestinal tract
20 Mesenterium commune 2
Colonic atresia 1
16
Esophageal atresia Vogt IIIb 1
12 Gallbladder agenesia 1
Hirschsprung’s disease 1
8
Renal
4 Double renal system 2
Complex syndromes
0
newborn babies toddlers school OEIS 1
children Genetic disease
Mucoviscidosis 1
Fig. 1 Mean age within each of the four age groups

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Table 2 Diseases and number which were caused for ACS

Primary
Peritonitis 7 Post appendectomy 3
Anastomotic leak following right hemicolectomy 1
Anastomotic leak following appendectomy 1
Traumatic small bowel perforation 1
Perforated appendicitis 1
Polytrauma 7 Nephrectomy, splenectomy 1
Splenic rupture, liver contusion 1
Retroperitoneal hematoma following rupture of left internal iliac vein and artery 1
Tearing of V. cava inferior, liver veins, splenic capsule 1
Splenektomie for splenic rupture, cholezystectomie, 1
liver rupture, retroperitoneal hematoma
Splenic and liver rupture, splenectomy, 1
Partial liver resection 1
Liver rupture grades 3–4 1
Perforation 2 Duodenal perforation due to bowel ischemia 1
Following resection of neuroblastoma
Ileal perforation following multiple laparotomies 4
NEC 4 With ischemia of small and large bowel 1
Pancreatitis 1 Following appendectomy
Intraabdominal bleeding, retroperitoneal hematoma 1 Anticoagulation after acute paraplegia 1
Ileus 3 Ileus due to adhesions following surgery for enterothorax 1
Following repair of volvulus and small bowel perforation 1
Adhesions 1
Secondary
Sepsis 2 Following abortion with sepsis 1
Empyema of the knee joint 1
Burn 1 8% burn of body surface area, IIa–b 1

clinical means as, for example, abdominal distension, aci-
dosis and otherwise unexplainable decrease in urine output,
respectively. The bladder was filled via an urinary catheter
with 1 ml of NaCl/kg bodyweight while the patient was
positioned supine. A three-way stopcock was established and
connected to an infusion set filled with NaCl in order to build
a water column which served as indirect IAP indicator (scale:
mm; reference point: symphysis [=zero point]). If the IAP lay
repeatedly above 12 mmHg and at least one organ showed
dysfunction, a diagnosis of ACS was made. Preoperatively,
the mean IAD was 18.5 (±3.1) mmHg, with a postoperative
drop down to a mean of 9.3 (±1.2) mmHg. The diagnosis
‘‘ACS’’ was defined as repeatedly measured elevated intra-
abdominal hypertension ([12 mmHg) accompanied by at
least one organ dysfunction [6].
Primary and secondary ACS
Primary ACS clearly predominated the study group and
was found in 25 children (89.3%). Within the group of
primary ACS 50% resulted from polytrauma and
peritonitis, while 32.1% (9/28) were due to bowel
perforation or ileus. In 7.1% of cases (2/28) the
underlying causes were pancreatitis (1/28) and intra-
abdominal bleeding (1/28) leading to the appearance of
retroperitoneal hematoma. Three children (10.7%)
presented secondary ACS with sepsis (2 cases) and
combustion (1 case) being the underlying diseases
(Table 2).
Previous abdominal surgery
For 13 children (46.4%) decompressive surgery was their
first intraabdominal intervention, while 15 children
(53.6%) had undergone at least one abdominal operation
before. Eight of them (53.3%) had been previously oper-
ated once, four patients twice (26.7%) and three children
thrice (20%). Severity of operations was distinguished into
small, middle and major interventions (for details see
Table 3).

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402
Table 3 Classification in small, medium and major operations
Minor
5 Appendectomy
3 Second look
1 Abdominal closure
1 Exploration and refashioning of ileostoma
Middle
2 Evacuation of retroperitoneal hematoma
1 Revision for ileus and peritonitis
1 Adhaesiolysis
1 Hysterectomy
1 Appendectomy and adhaesiolysis
1 Partial jejunal resection
1 Closure of small bowel fistula
1 Debridement of burn wounds
1 Refashioning of jejunostomy
Major
8 Bowel resection
1 Repair of bladder exstrophy, cecal reconstruction and
ascendostoma
1 Right hemicolectomy
1 Partial pancreatic necrosectomy, splenectomy
1 Excision of retroperitoneal neuroblastoma
Surgery
In all children ACS decompression of the abdominal cavity
was carried out by performing a transverse laparotomy and
creating a laparostoma by implantation of an absorbable
mesh, which was fixed to the fascial layer using an absorb-
able running suture (Fig. 2). Depending on the postoperative
course, this mesh either was removed while reconnecting
fascial layers directly, or the mesh was left in situ until
granulation tissue had overgrown the whole implant. In 18
children direct closure was carried out, the remaining ten
wounds healed by secondary intention. In two children an
additional split skin graft was necessary. The median time
until closure of the abdominal cavity could be performed was
53 days (range 10–63 days). In six children repeated
Vicryl" mesh reduction was needed to minimize the wound
surface and tension prior to the final surgical closure.
The most frequent complication (6/28) observed was
formation of an enterocutaneous fistula (21.4%). Fistulae
were either oversewn or excised. In two children a mesh
tear occurred at the junction with the fascia and made re-
adaptation necessary.
Lethality
22 of 28 children (78.6%) survived. Underlying cause of
death in the other six cases (22.4%) was sepsis with
multi-organ failure (MOF). Two children died on the
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Pediatr Surg Int (2011) 27:399–405
Fig. 2 Implantation of a Vicryl" mesh in the abdominal wall by a
three months-aged girl after decompression laparotomy because of
ACS
day of admission, the other five within 9 days of
hospitalization.
Long-term results
Median follow-up time was 6.8 years (range 2.2–10 years).
Further surgical interventions during follow-up included
incisional hernia repair 6 cases (27.3%), closure of a stoma
(one case) and relaparotomy for ileus due to adhesions (one
case).
A questionnaire was sent to the parents of 22 surviving
children with a resulting response rate of 72.7% (16/22).
According to the answers given in the questionnaire the
scar area keeps discomforting 10 of 16 children physio-
logically or psychologically (62.5%). Of those, subjective
impediment degree was put at 100% by five children
(31.3%), at 80% by one child (6.3%) and at 50% by two
patients (12.5%).
Discussion
Few and just low-evidenced studies exist reporting exclu-
sively about ACS in childhood. Released results corre-
spond to our findings, although a direct comparison is not
possible on account of the different study designs [5–9].
ACS occurs at any age in children. A division into different
age groups has not been carried out yet by any of the
named authors. All cited reports describe a predominance
of the male gender, being stated at 61.8%.
The presence of associated malformations in children
with ACS is mentioned only in single reports. Diaz found
malformations in 40% of children with ACS [1, 5]. This is
in accordance with our own results, which showed the
occurrence of malformations or genetic disorders to be
Pediatr Surg Int (2011) 27:399–405
46.1%. Literature research [1, 5–9] revealed the primary
ACS to occur nearly twice as frequently as secondary and
tertiary ACS together (62.1 vs. 37.9%).
Retrospectively, further distinction between secondary
and tertiary ACS could not be worked out against the
background of insufficient data. Our own data revealed a
higher ratio in favor of the primary ACS with a share of
89%. Due to our complete dataset a differentiation between
primary and secondary ACS was well possible. In the lit-
erature only few studies did carry out a division into pri-
mary and secondary ACS [5–9].
Primary ACS defines all forms of ACS resulting from
intraabdominal diseases and entities. Against that, sec-
ondary ACS derives from disarrangements arising from
outside the abdominal cavity including pneumonia, extra-
abdominal trauma, burns with capillary leak syndrome or
the need of high-fluid resuscitation, for example [10].
Tertiary ACS is defined as recurrent ACS following an
initially successful treatment of primary ACS, e.g. after
decompressive laparotomy [4].
Concerning the diagnosis of ACS or intraabdominal
hypertension (IAH) no generally valid approach exists
which was demonstrated by data resulting from a ques-
tionnaire sent to members of the Society of Critical Care
[11]. 20% of the responders base their diagnosis IAH
exclusively on clinical signs, 7.2% strictly use intravesical
pressure-measurements and about 70% a combination of
both. The remaining 2.8% use other methods. According to
the WSACS (World Society of the Abdominal Compart-
ment Syndrome) an ACS is defined as rise of the IAP
above 20 mmHg with or without an APP (abdominal per-
fusion pressure) less than 60 mmHg in combination with a
new onset of organ dysfunction [12, 13]. There is no evi-
dence whether the above-mentioned criteria also apply for
physiological conditions in children. Several authors sug-
gest IAH-limits as low as 10–15 mmHg to be detrimental
in childhood and to build the critical pressure head at which
regularly a switch from IAH to ACS in pediatric patients
can be observed [1, 5, 6]. According to Eijke [6] we
therefore defined pediatric ACS as a lasting IAH higher
Table 4 Causes for primary ACS
Beck [1] DeCou [18]
Abd. bleeding 2
Bowel perforation 1 2
Ileus 1 2
Abd. trauma 1 2
Abd. tumor 2 2
Peritonitis excluding bowel perforation 4 1
NEC/colitis 1 1
Pancreatitis
403
than 12 mmHg combined with at least one organ
dysfunction.
In adults, the intravesical pressure measurement is
considered as gold standard for the indirect IAP measure-
ment. Using this intermittent method which was first
described by Bertram et al. [4], a measuring volume of
50 ml sterile saline is inserted. Against that, the recom-
mended volumes in children vary between 1 ml/kg [13–15]
and 2 ml/kg of body weight [16]. Concerning our study a
filling amount of 1 ml/kg of body weight was enough to
reliably determine the IAP. This is in accordance with data
from Suominen who proved high correlation to the directly
measured IAP when filling the bladder with 1 ml/kg of
body weight [15]. As soon as measurements are performed
in fixed or traumatized bladders untrustworthy pressure
heads result [12]. Other situations rendering this technique
unreliably are body positions other than supine, pre-exist-
ing peritoneal adhesions or preceding abdominal packing
[12, 17]. Possible risks of bladder pressure measurements
frequently pointed out by critics are damage and infection
of the urinary tract. Nevertheless, Malbrain found the
infection risk not to be raised when using a closed mea-
suring system with three-way stopcock [12].
A huge number of causes are considered to be causative
for the development of IAH and ACS. Our own evaluation
revealed peritonitis and polytrauma to be predominant with
each 25%. This is noteworthy in so far as in the present
literature peritonitis was not looked upon as an origin of an
ACS, yet. This might be explain by the fact that authors all
illnesses which first lead to peritonitis and after that to ACS
deem causative for the development of IAH and ACS. In
their opinion, also peritonitis is just a consequence of
another disarrangement and builds an intermediate stage on
the way to an ACS. Polytrauma as an underlying cause for
ACS was also mentioned by other investigators: deCou
reported three exemplary cases [18] and Neville found a
share of 13% being traumatized before developing an ACS
[9]. Beck [1] analyzed medical records of 1762 pediatric
patients who were sent to ICU and revealed a trauma-
induced ACS-incidence of 0.7% related to patients who
Diaz [5] Eijke [6] Kawar [19] Neville [9] Aachen
4 2
1 3
1 1 7
1 1
1 7
15 4
1
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Table 5 Causes for secondary ACS

Beck [1] DeCou [18] Diaz [5] Eijke [6] Jensen [16] Maxwell [8] Morrell [20] Aachen

Cerebral disease 4
Polytrauma 1 3 1 1 1
Combustion 2 3 1
Sepsis 3 3 2
Cardiac disease 2
Pneumonia 1

Fig. 3 Flow sheet for

Surveillance of patients at risk for 12 h, intervals at 1-2 h
monitoring in risk patients

>20 mmHg
<12 mmHg 12-15 mmHg 16-20 mmHg and
or
No organ dysfunction >16 mmHg
with organ
dysfunction
24 h IAD
monitoring: conservative therapy and IAP-monitoring
every 4-6 h

ACS

<12 mmHg >12 mmHg Secondary or

primary
tertiary

Stop Start yes conservative

monitoring at top operative
therapy
decompression
exhausted?

no

no
success conservative therapy
Monitor IAP every 4 h
Aim: APP >60 mmHg
successful

<20 mmHg > 20 mmHg

Attempt
abdominal closure

<12 mmHg >12 mmH g

stop
measurement

have had an accident (3/406) and an incidence of 0.2% to be the main origin (56.6%) [9]. According to the sec-
based on all patients admitted to the ICU (3/1762). Of all ondary ACS, a comparably wide range of possibly under-
23 children who developed ACS and had to be decom- lying reasons has been published. Summarized infection
pressed by laparotomy in his cohorte, Neville stated NEC and sepsis account for the vast majority of perpetrators,

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Pediatr Surg Int (2011) 27:399–405
followed by combustion and trauma (Tables 4, 5). The
diagnosis of an ACS requires the appropriate clinical signs
and a rise in bladder pressure above 12 mmHg [4, 13].
Decision making after recognition of ACS was facili-
tated by a therapeutic algorithm (Fig. 3) which was
developed and adapted from recommendations provided by
Kimball and DeLaet. The most important difference
between both authors lies in the therapy following the
diagnosis of an ACS. With respect to their advices con-
cerning the therapy of choice in cases of ascertained ACS,
both authors argument controversially. While Kimball
recommends an immediate decompression when ACS is
diagnosed (irrespective of the ACS being primary, sec-
ondary or tertiary), DeLaet prefers a less invasive man-
agement and suggests to proceed conservative therapy in
cases of secondary and tertiary ACS, if reasonable [21, 22].
Efficient therapeutic intervention for ACS consists of an
immediate decompression of the abdomen and correction
of the underlying cause, if conservative therapy options
foreseeable deliver frustrating results. The implantation of
absorbable mesh (e.g. Vicryl") has proven itself so far as
meshes can be removed as soon as patients broadly become
reconvalescent or alternatively may remain in situ till
resorption with secondary granulation has achieved [4, 23].
Cheatham investigated adults with necessity of abdominal
decompression and revealed no negative influence by lap-
arotomy [24].
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