Pneumoperitoneum, pneumatosis intestinalis and portal venous gas: Rare gastrostomy complications case report

Is reoperation required for patients presenting with hepatic portal venous gas after gastrointestinal surgery: a review of the literature

BACKGROUND AND OBJECTIVE

Hepatic portal venous gas(HPVG) represents a rare radiographic phenomenon frequently linked to intestinal necrosis, historically deemed to need immediate surgical intervention. The pivotal query arises about the imperative of urgent surgery when a patient manifests HPVG after gastrointestinal surgery. This inquiry seeks to elucidate whether emergent surgical measures remain a requisite in such cases.

METHODS

The investigation into 14 cases of HPVG after gastrointestinal procedures was conducted through a comprehensive review of relevant literature. This methodological approach contributes to a nuanced understanding of HPVG occurrences following gastrointestinal surgery, informing clinical considerations and potential therapeutic strategies.

RESULTS

Among the 14 patients, 12 recovered and 2 died. 6 patients underwent surgical exploration, 4 with negative findings and recovered. 8 cases received conservative treatment, resulting in improvement for 5, and 1 initially treated conservatively, revealed perforation during later surgical exploration, leading to improvement, 1 case ended in mortality.

CONCLUSION

After gastrointestinal surgery, in Computed Tomography (CT) imaging, the coexistence of HPVG and gastrointestinal dilatation, without signs of peritoneal irritation on abdominal examination, may suggest HPVG due to acute gastrointestinal injury, intestinal gas, and displacement of gas-producing bacteria. These patients can be managed conservatively under close supervision. In cases where HPVG coexists with gastrointestinal dilatation and Pneumatosis intestinalis (PI) without signs of peritoneal irritation, conservative treatment may be continued under close supervision. However, if progressive exacerbation occurs despite close monitoring and the aforementioned treatments, timely surgical exploration is deemed necessary. When HPVG is combined with signs of peritoneal irritation, prompt laparotomy and exploration are preferred.

Pneumatosis Intestinalis Following Surgical Gastrostomy Tube Placement in a Patient With Glottic Squamous Cell Carcinoma: A Case Report

Pneumatosis intestinalis (PI) is a rare medical and post-surgical sequela of multiple different etiologies which can be either benign or life-threatening. Various mechanisms have been proposed to explain the occurrence of PI; however, the pathophysiology is dependent on the suspected cause. The condition is largely categorized into two broad groups: idiopathic PI, which remains relatively uncommon, and secondary PI. The latter often surfaces as a result of a wide array of both gastrointestinal and non-gastrointestinal illnesses. These encompass vascular compromise, bowel mucosal disruption, gastrointestinal dysmotility, as well as infectious and immunological etiologies. Management ranges from conservative medical strategies to emergent surgical intervention. We present the first case to our knowledge of spontaneous PI developing within five days of a surgical gastrostomy tube (SGT) placement in a 79-year-old female with glottic squamous cell carcinoma which unfortunately proved fatal. The purpose of this case report is to highlight a rare fatal complication of a common surgical procedure and the necessity of initiating interdisciplinary management quickly to determine the best treatment course.

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

PURPOSE

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention.

METHODS

A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases.

RESULTS

A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings.

CONCLUSIONS

Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

The characteristics of residual pneumoperitoneum after laparoscopic colorectal surgery

INTRODUCTION

Despite the popularity of laparoscopic surgery, it remains unclear whether residual pneumoperitoneum influences the patient's postoperative course. This study aimed to evaluate the characteristics of residual pneumoperitoneum.

METHODS

This retrospective study included 201 Japanese patients who had undergone elective laparoscopic colorectal surgery. The patients were divided into groups, with and without anastomotic failure; the non-anastomotic failure group was further divided into subgroups, with and without residual pneumoperitoneum. Patient characteristics were compared between the various groups.

RESULTS

The group with residual pneumoperitoneum included 57 patients (30.3%). Percutaneous drainage was required for one patient with residual pneumoperitoneum. Univariate analyses revealed that residual pneumoperitoneum was associated with low values for body mass index (BMI) and subcutaneous fat area (SFA). Furthermore, relative to the group with anastomotic failure, the group without anastomotic failure but with residual pneumoperitoneum had lower values for inflammatory markers.

CONCLUSION

Low BMI and SFA values were identified as risk factors for residual pneumoperitoneum. Inflammatory markers may be useful as indicators for avoiding emergent surgery when it is difficult to differentiate between asymptomatic residual pneumoperitoneum and free air related to anastomotic failure.

Pneumatosis Intestinalis and Hepatic Portal Venous Gas: Watch and Wait or Emergency Surgery? A Case Report and Literature Review

Patient: Female, 60-year-old

Final Diagnosis: Pneumatosis intestinalis

Symptoms: Abdominal pain

Medication:—

Clinical Procedure: —

Specialty: Surgery