There is growing evidence in the literature that development of abdominal compartment syndrome (ACS) in patients with severe acute pancreatitis (SAP) has a strong impact on the course of disease [1–4]. The main causes for development of ACS during the course of SAP are: pancreatic and peripancreatic inflammation, visceral oedema caused by aggressive fluid resuscitation, presence of free fluid collection, and paresis of the bowel. Several studies clearly showed that development of organ failure in SAP is in correlation with presence of intraabdominal hypertension (IAH) [2, 3, 5, 6]. It seems that the number of patients with this complication has increased, due to more aggressive fluid resuscitation, a much bigger proportion of patients treated conservatively or by a minimal invasive approach, and efforts to delay open surgery.
Intra-abdominal hypertension reduces organ perfusion and may cause organ dysfunction [7, 8]. Increased intra-abdominal pressure (IAP) leads to hypoperfusion of the gastrointestinal tract and reduction of chest wall compliance . It has also been shown that an IAP above 20 mmHg can lead to oliguria and significant reduction in the cardiac output [10, 11]. IAH was associated with significantly higher APACHE II score and MODS score in patients with SAP [3, 4]. De Walle et al.  published a higher incidence of respiratory, circulatory and renal failure among the patients with IAH. In patients with severe acute pancreatitis, pancreatic perfusion is reduced, and IAH probably contributes to further development of pancreatic hypoperfusion and consequently necrosis.
Some recent studies suggested that ACS is a frequent finding in patients with SAP [3, 6, 8, 12, 13]. Tao et al.  reported a 36% incidence of ACS among 297 patients with SAP. In a recently published study Al-Barhani et al.  showed an incidence of 61% of IAH and 56% of ACS in a selected well-studied and monitored group of SAP patients. However, the lack of a definition of ACS and methodological issues, make interpretation of these results and some other studies difficult.
So far, there have not been standard recommendations for a surgical or some other interventional treatment of patients who develop ACS during the course of SAP . Despite the fact that World Society of Abdominal Compartment Syndrome (WSACS) published definition of IAH and ACS  and recommendation for the treatment , the appropriate surgical technique for the treatment of those patients suffering from SAP is still debated. Some procedures have been occasionally reported that could be useful and may be able to improve outcome of patients who develop ACS during SAP. Several authors published relief of ACS after insertion of drain under radiological guidance [12, 17–19]. Some others recommended decompressive laparotomy with subsequent laparostomy for the treatment of ACS [1, 8, 20–22]. Several investigators also suggested skin incisions to perform a subcutaneous fasciotomy with the peritoneum left intact [23, 24].
Sun et al.  performed a randomised study to compare effects of indwelling catheter and conservative measures in the treatment of ACS in fulminant acute pancreatitis. They found that drainage volume was positively correlated with intraabdoninal pressure, which also was correlated with hospitalization time and APACHE II score. Effects of the treatment in the group with abdominal catheter were significantly better than in conservative group, regarding relief of abdominal pain and hospitalization time. In addition mortality rate decreased from 20.7% to 10%, but without significant difference.
Decompressive laparotomy for ACS associated with SAP has not been studied in large patients group . Occasionally, there have been several case reports in the literature with high early mortality rate, ranging from 17 to 75% [1–6, 20–22, 25]. A high proportion of patients in these reports, during surgical decompression received retroperitoneal debridement and early mortality was mainly associated with uncontrolled retroperiotoneal bleeding . Current very limited experience supports the strategy of decompresive laparotomy in patients with ACS during SAP, but without premature exploration of pancreatic region and retroperitoneum .
All these data have not provided enough clear evidence to support a treatment algorithm for ACS in patients with SAP, although two approaches deserve more attention than other. These are decompresive laparotomy with temporary abdominal closure and percutaneous puncture with placement of abdominal catheter. Both of these procedures raise several unresolved issues such as for decompresive laparotomy: a) the relation to potential necrosectomy, b) difficulties in management of semi-open abdomen, c) increased risk of enteric fistulas d) potentially higher number patients with infected pancreatic necrosis than expected e) incidence of postoperative hernias. The main unanswered question for percutaneous puncture with placement of abdominal catheter is whether using this procedure is possible to achieve sufficient decompression and relief of ACS.
We anticipated that decompresive laparotomy with temporary abdominal closure, beside all potentially negative side effects that early open surgery carries in patients with acute pancreatitis, may result in decrease of overall mortality and major morbidity. The DECOMPRESS study is designed to compare effects of decompresive laparotomy with temporary abdominal closure and percutaneous puncture with placement of abdominal catheter in patients with abdominal compartment syndrome during acute pancreatitis.