Distant free air is not a contraindication for definitive laparoscopic treatment of acute perforated diverticulitis: a multi-center experience

The paradigm of emergency laparotomy with sigmoid resection and protective stoma has been challenged for perforated diverticular disease (PDD) with free extraluminal air. Early clinical stabilization could lead to interval laparoscopic resection without stoma within 2 weeks from perforation. Patients admitted for acute diverticulitis underwent abdominal computed tomography (CT) scan. When free air was seen, endoluminal enema was administred. All patients underwent assessement of clinical stability. In unstable patients, upfront emergency surgery was performed. Stable patients underwent a conservative management consisting in fasting, central line intravenous fluids, antibiotic therapy, pain management, O₂ therapy and percutaneous radiological drainage when indicated. In successful conservative management early interval surgery was planned within 15 days. Early delayed definitive laparoscopic treatment (EDDLT) was defined as laparoscopic resection of the affected colon without ostomy. A total of 235 patients were admitted to the emergency department for PDD. Among these, 142 had pericolic free air and were excluded from the study. Ninety-three had distant free air. Thirty-seven were hemodynamically unstable and underwent upfront surgery. Fifty-six patients showed a clinical stability and started on EDDLT. EDDLT was successfully performed in 36 patients (64.3%). In 20 patients (35.7%) EDDLT was unsuccessful. At multivariate analysis, distant CT extravasation of endoluminal contrast was independently associated with unsuccessful EDDLT (OR 2.1, CI 0.94-5.32). Patients with distant extraluminal free air after PDD may be treated with early delayed surgery after intensive medical therapy. Distant spread of endoluminal contrast at CT was a risk factor for unsuccessful EDDLT often indicating fecal peritonitis.

Diagnosis at gut point: rapid identification of pneumoperitoneum via point-of-care ultrasound

Undifferentiated abdominal pain is a common presentation often requiring immediate medical or surgical intervention. Providing an accurate diagnosis involves a detailed patient history and thorough physical exam. Point of care ultrasound is gaining acceptance as a rapid diagnostic tool that can be used to accurately detect life-threatening conditions while potentially avoiding unnecessary radiation exposure and facilitating rapid treatment. Detection of pneumoperitoneum with point-of-care ultrasound is a simple procedure that relies heavily on the experience of the investigating practitioner. Standard technique involves placing a high-frequency linear-array transducer in the right upper quadrant, where abdominal free air is most likely to accumulate. Detection of the ‘gut point’, which is the transition of abdominal wall sliding to lack thereof in a single image, is the pathognomonic finding of pneumoperitoneum. If visualization is difficult, moving the patient to the left lateral decubitus position or using the scissors technique can provide additional image views. This representative case report and review highlights the use of abdominal POCUS for the diagnosis of pneumoperitoneum. Ultrasound should continue to be explored by clinicians to narrow the differential diagnosis of acute abdominal pain.

The clinical significance of extraluminal air in Hinchey 1a diverticulitis: results from a retrospective cohort study with 10-year follow-up

BACKGROUND

Some patients with uncomplicated diverticulitis have extraluminal air. Our objective was to determine if patients with Hinchey 1a diverticulitis and isolated extraluminal air present more severe episode than patients without extraluminal air.

METHODS

The present study is a monocentric observational retrospective cohort study. Computed tomographies of patients with diagnosed uncomplicated diverticulitis were retrospectively reviewed from the 01 January 2005 to the 31 December 2009. The presence of extraluminal air was determined. Leukocyte count, CRP value, and length of hospitalization were extracted from the patients' files. The follow-up period was from the time of diagnosis to the 15th of March 2019, the latest. Follow-up was censored for death and sigmoidectomy. Recurrence and emergency sigmoidectomy were documented during the follow-up period. The study was performed according to the STROBE guideline.

RESULTS

Three hundred and one patients with an episode of Hinchey 1a diverticulitis were included. Extraluminal air was present in 56 patients (18.60%). Leukocyte count (12.4 ± 4.1(G/l) versus 10.7 ± 3.5(G/l), p = 0.05), CRP value (156.9 ± 95.1(mg/l) versus 89.9 ± 74.8(mg/l), p < 0.001), and length of hospital stay (10.9 ± 5.5(days) versus 8.4 ± 3.6(days), p < 0.001) were significantly higher in patients with extraluminal air than in patients without extraluminal air. Seventy-two patients (23.92%) presented a recurrence during the follow-up period. Survival estimates did not differ between patients with or without extraluminal air (p = 0.717). Eleven patients (3.65%) required emergency surgery during the follow-up period. Patients with extraluminal air had shorter emergency surgery-free survival than patients without extraluminal air (p < 0.05).

CONCLUSION

The presence of extraluminal air in Hinchey 1a diverticulitis indicates a more severe episode, with higher inflammation parameters at admission, longer length of stay, and an increased risk for emergency sigmoidectomy.

Pneumatosis Intestinalis After Molecular-Targeted Therapy

BACKGROUND

Pneumoperitoneum after surgical manipulation of the abdomen implies a perforation. Rare cases of nonoperated cancer patients, largely with gastrointestinal or genitourinary cancers, have been noted to have radiologic findings of pneumatosis intestinalis and/or pneumoperitoneum as a complication of molecular-targeted therapy (MTT) without confounding factors for perforation. We present a patient with a cranial malignancy treated with bevacizumab who subsequently manifested with pneumatosis intestinalis.

CASE DESCRIPTION

A 67-year-old man with metastatic melanoma, non-small cell lung cancer, and recurrent cerebellar subependymoma was initiated on bevacizumab treatment for subependymoma recurrence. He subsequently underwent an uncomplicated ventriculoperitoneal shunt for progressive obstructive hydrocephalus, confirmed by a normal postoperative abdominal radiograph. One week later, he returned with worsening lethargy and a computed tomography consistent with pneumomediastinum and pneumoperitoneum. Due to concern for bowel perforation, the patient underwent diagnostic laparoscopy and removal of ventriculoperitoneal shunt. Focal sigmoid pneumatosis was identified without any signs of bowel perforation or ischemia. Bevacizumab was discontinued, and the patient's radiologic and clinical findings improved.

CONCLUSIONS

With increasing utilization of MTTs in brain tumor management, we raise MTT as a potential cause for pneumoperitoneum in neurosurgical patients. Pneumoperitoneum after extracranial procedures still requires workup and management for potential bowel perforation, but alternative causes such as bevacizumab should also be considered. Pneumatosis intestinalis patients on MTT can have benign physical examinations and will resolve, in the majority of cases, on discontinuation of the drug.

Pneumo-thorax/mediastinum/(retro)peritoneum/ scrotum - a full house of complications following JET ventilation

We present a patient who presented to our clinic with airway obstruction secondary to oropharygeal cancer. He underwent emergent tracheostomy with JET ventilation, the latter resulting in a "full house" of barotraumatic complications including pneumothorax, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum and pneumo-scrotum. Free air, while sometimes dramatic as in our case, need not always be a cause for alarm and can often be managed expectantly. Our patient was treated with only a chest drain and otherwise made an uneventful recovery.

Vacuum phenomenon

This article describes the theory of the formation of the vacuum phenomenon (VP), the detection of the VP, the different medical causes, the different locations of the presentation of the VP, and the differential diagnoses. In the human body, the cavitation effect is recognized on radiological studies; it is called the VP. The mechanism responsible for the formation of the VP is as follows: if an enclosed tissue space is allowed to expand as a rebound phenomenon after an external impact, the volume within the enclosed space will increase. In the setting of expanding volume, the pressure within the space will decrease. The solubility of the gas in the enclosed space will decrease as the pressure of the space decreases. Decreased solubility allows a gas to leave a solution. Clinically, the pathologies associated with the VP have been reported to mainly include the normal joint motion, degeneration of the intervertebral discs or joints, and trauma. The frequent use of CT for trauma patients and the high spatial resolution of CT images might produce the greatest number of chances to detect the VP in trauma patients. The VP is observed at locations that experience a traumatic impact; thus, an analysis of the VP may be useful for elucidating the mechanism of an injury. When the VP is located in the abdomen, it is important to include perforation of the digestive tract in the differential diagnosis. The presence of the VP in trauma patients does not itself influence the final outcome.

Postoperative pneumoperitoneum: is it normal or pathologic?

BACKGROUND

Pneumoperitoneum on computed tomography (CT) after abdominal surgery is common, but its incidence, duration, and clinical significance is widely debated.

MATERIALS AND METHODS

A retrospective, cohort study of patients who underwent abdominal CT within 30 days of abdominal surgery.

RESULTS

Among 344 patients, pneumoperitoneum was found in 39% (135/344) of patients on postoperative days 0-6 in 53%, 7-13 in 41%, 14-20 in 23%, 21-27 in 13%, and 28-30 in 0%. Pneumoperitoneum was associated with the presence of a drain (P = 0.014) but not with age, gender, body mass index, smoking history, lung disease, or open versus laparoscopic surgery (P > 0.05 for all variables). Eight patients required intervention (6%), most commonly for anastomotic leak (4 patients, 50%).

CONCLUSIONS

Postoperative pneumoperitoneum on abdominal CT can be seen in up to 23% of patients 3-weeks postoperatively; however, only 6% of the patients required intervention emphasizing the typically benign consequences of postoperative free air.