O. Fauver1, G. An1 1University Of Vermont College Of Medicine / Fletcher Allen Health Care, Surgery, Burlington, VT, USA
Introduction: Intestinal pneumatosis (IP) has traditionally been a signifier of severe disease that mandates immediate surgical exploration. However, with improvements in the resolution of computed tomography leading to the ability to capture greater anatomic detail there has been a reassessment of several historical surgical dicta, with an increasing suggestion that this is also true for IP. A recent review (World J Gastrointest Surg. 2023 Apr 27;15(4):553-565) notes the importance of contextualizing the radiographic finding of IP with clinical presentation, medical history and laboratory values in determining if abdominal exploration is warranted. We examine our own experience with IP as an acute care surgical service, which would be expected to be the surgical service responding to this finding, at an academic institution.
Methods: We reviewed our Emergency General Surgery Registry for the year range 2017 to 2024 for patients that were coded with “pneumatosis.” Patient features were collected including confirmation of radiographic diagnosis, severity at time of clinical presentation, whether patients underwent abdominal exploration, findings if exploration was undertaken, and outcome.
Results: We identified 14 patients that were labeled with “pneumatosis” in our registry from 2017 to 2024. Of these 5 patients were mis-labeled, primarily due to the conflation of “free peritoneal air” with “pneumatosis.” Of the 9 patients that were confirmed to have radiographic evidence of pneumatosis, 5 patients underwent abdominal exploration and 4 were treated non-operatively. All non-operative patients were hemodynamically stable without signs of septic shock and without generalized peritonitis and were eventually discharged alive. In terms of laboratory values, all these patients had lactate levels of < 3 mmol/L and white blood cell counts of < 14 K/cmm. Of the 5 patients who underwent exploration, all had either peritonitis and/or were in shock. Of these 2 patients did have full thickness ischemic/infarcted bowel and underwent resection, whereas the remaining 3 did not have evidence of compromised bowel and no resection was done. The resected patients all survived, whereas 2 of the 3 patients with negative laparotomies expired from progressive septic shock.
Conclusion: IP may be increasingly recognized with modern computed tomography, with a consequent effect on its traditional role in mandating emergent abdominal exploration. The experience of our acute care surgery service, though small in numbers, appears to be consistent with trends suggesting the need to evaluate the radiographic finding in the patient’s global clinical and laboratory context. Interestingly, in our admittedly small numbers, the correlation between the radiographic finding and evidence of actual bowel ischemia/infarction was limited.