Non-surgical Pneumoperitoneum in the Setting of Gram-negative Sepsis

Robot-Assisted Diagnostic Laparoscopy: A Safe and Feasible Adjunct to the Management of Massive Spontaneous Pneumoperitoneum

Pneumoperitoneum is the abnormal presence of free air in the peritoneal cavity. Oftentimes, it is a surgical emergency requiring exploratory laparotomy as most cases of pneumoperitoneum are due to perforated hollow viscus. However, not all pneumoperitoneum cases are surgical; nonsurgical pneumoperitoneum can arise from thoracic, abdominal, gynecologic, and other causes. We present a case of a 35-year-old male who developed a non-surgical pneumoperitoneum in the setting of drug overdose. The patient underwent robot-assisted diagnostic laparoscopy without findings of perforation or other pathology. Resolution of pneumoperitoneum was evidenced on follow-up computed tomography scan. This case emphasizes the importance of diagnostic laparoscopy in the setting of a confusing clinical picture and the feasibility of utilizing the robotic approach in hemodynamically stable patients.

[Spontaneous idiopathic pneumoperitoneum in a patient with COVID-19]

The authors present a patient with COVID-19 and spontaneous idiopathic pneumoperitoneum. A 77-year-old man suffering from coronary artery disease, diabetes mellitus and cognitive disorders was diagnosed with bilateral pneumonia and COVID-19. Oxygen support through a face mask was prescribed. After 21 days, oxygen saturation decrease and mild abdominal symptoms required CT-based examination. Pneumoperitoneum without pneumothorax and pneumomediastinum was revealed. Explorative laparotomy found no abdominal diseases. According to the literature, spontaneous pneumoperitoneum in patients with COVID-19 is usually associated with high pressure oxygen therapy, but not always associated with intrathoracic complications. Conservative treatment may be appropriate in patients with spontaneous pneumoperitoneum, but any unclear findings can require surgery.

A Rare Case of Spontaneous Idiopathic Pneumoperitoneum Presenting as Abdominal Pain

Idiopathic spontaneous pneumoperitoneum is caused by free air in the peritoneum when no established cause has been diagnosed. We present the case of a 61-year-old male with idiopathic spontaneous pneumoperitoneum, which started as abrupt abdominal pain. He described burning abdominal pain radiating to his right shoulder and endorsed symptoms of nausea, abdominal bloating, and heartburn but denied fever, chills, or vomiting. Chest radiograph and computed tomography demonstrated massive amounts of free air under the diaphragm, concluding an extensive pneumoperitoneum. He was diagnosed by standard imaging modalities and then underwent diagnostic laparoscopy, which did not reveal any areas of perforation. Subsequently, the patient had an uncomplicated recovery. The complexity of diagnosis and treatment has made it difficult for surgeons to treat spontaneous pneumoperitoneum patients. 

Negative surgical exploration in suspected gastrointestinal perforation: trend, preoperative predictors, and etiologies

Background

Despite the rapid improvement of clinical science and imaging technology including computed tomography, the entity of negative surgical exploration in suspected gastrointestinal perforation (N-GIP) still exist. However, few studies have focused on this issue and most studies are case reports. We undertook this study to investigate the rates of N-GIP, and explore a set of possible preoperative predictors associated with N-GIP.

Methods

This was a retrospective study performed at the department of general surgery in our treatment center. All patients included were suspected gastrointestinal perforation (GIP) cases, aged 14 years and over, and underwent emergency surgery between 2009 and 2019. A predictive multivariable model of the presence of N-GIP was developed using logistic regression analysis.

Results

A total of 973 patients were identified and 30 (3.1%) were found to have no evidence of perforated gastrointestinal tract. The mean age of patients was 59.74 (range, 14–97) years, and 67.2 percent of the patients were males. The rates of N-GIP did not have a significant change over time (P=0.212 for trend). In multivariable analysis, absence of generalized peritonitis, duration of abdominal pain >19.6 hours, and neutrophil-to-lymphocyte ratio (NLR) <3.80 were significant predictors of N-GIP. N-GIP was more common in patients with gastrointestinal tumors and foreign bodies. Five patients (16.7%) in N-GIP group experienced complications and the 90-day mortality rate was 6.7%.

Conclusions

The rates of N-GIP did not change significantly over time. N-GIP was associated with the absence of generalized peritonitis, duration of abdominal pain >19.6 hours, and NLR <3.80.

Asymptomatic pneumoperitoneum in pneumatosis coli: A misleading operative indication

INTRODUCTION

Pneumatosis cystoides intestinalis (PCI) is a rare clinical pathology characterized by sub-mucosal and/or sub-serous cysts of free gas, forming cystic lesions usually ranging from 0.5 to 2.0 cm in size within the gastrointestinal tract. About 3% of patients with PCI develop complications such as pneumoperitoneum, intestinal volvulus, obstruction, or hemorrhage, these cases need immediate surgical intervention. Cyst rupture can produce peritoneal irritation and pneumoperitoneum.

PRESENTATION OF CASE

A 65-years-old woman was admitted to the Emergency Department for epileptiform convulsions. Her medical hystory included epilepsy, diabetes, lichenoid dermatitis, hypothyroidism, severe cognitive impairment. Abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated to extensive pneumoperitoneum. The patient underwent emergency laparotomy which revealed the presence of gas within the wall of right and transverse colon and distension of great omentum. No resection was needed as normal blood supply to the bowel present.

DISCUSSION

Pneumatosis coli can be both asymptomatic or life-threatening condition associated to bowel infarction; this situation can mimic a bowel perforation causing pneumoperitoneum - that sometimes is a non-surgical pneumoperitoneum - and it could be a misleading indication to surgical exploration especially in the case of uncertain origin of a septic shock.

CONCLUSIONS

We report a case of pneuomoperitoneum due to PCI. Surgical intervention was required for patient's conditions and unclear origin of the sepsis.

Chronic Spontaneous Pneumoperitoneum with Pneumatosis Cystoides Intestinalis of the Small and Large Intestine

Pneumoperitoneum can be an alarming radiological finding and a manifestation of a surgical emergency that warrant urgent intervention, or it can be a manifestation of chronic benign condition that can be managed conservatively. The sequela of misdiagnosing pneumoperitoneum due to surgical abdomen as a chronic benign pneumoperitoneum can be life-threatening and misdiagnosing chronic spontaneous pneumoperitoneum due to chronic condition as surgical emergency will lead to unnecessary surgical interventions. Diagnosis of chronic spontaneous pneumoperitoneum can be challenging to the unwary healthcare-providers. We present a case of chronic pneumoperitoneum secondary to pneumatosis cystoides intestinalis that has been managed conservatively.