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Free Air in the Postoperative CT Patient: Observe or Operate?

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Book cover Difficult Decisions in Cardiothoracic Critical Care Surgery

Part of the book series: Difficult Decisions in Surgery: An Evidence-Based Approach ((DDSURGERY))

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Abstract

The finding of free air on postoperative imaging creates a difficult scenario for the clinician triggering immediate action. A quick decision needs to be made to determine whether the free air is related to a GI perforation and whether surgical intervention is required. In select cases, some patients can undergo expectant observation. There have been numerous studies both retrospective and prospective, attempting to determine the incidence, duration, and characteristics of “benign,” postoperative pneumoperitoneum. Overall, the duration of a benign postoperative pneumoperitoneum can vary greatly but often tends to reabsorb within 1–2 weeks and is usually of a small volume. It is also important to remember that CT scans are much more sensitive for picking up free air than plain films so the finding of “benign” free air on a postoperative CT scan is much more likely than on plain films. The most important general conclusion from the literature is that there is a percentage of patients with free air found on imaging that can be observed; however, observing for, and consideration of surgical peritonitis should be an ongoing concern and continuously reassessed.

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References

  1. Harrison I, Litwer H, Gerwig WH Jr. Studies on the incidence and duration of postoperative pneumoperitoneum. Ann Surg. 1957;145(4):591–4.

    Article  CAS  Google Scholar 

  2. Brandl A, Kratzer T, Kafka-Ritsch R, et al. Diverticulitis in immunosuppressed patients: a fatal outcome requiring a new approach? Can J Surg. 2016;59(4):254–61.

    Article  Google Scholar 

  3. Lagercrantz E, Lindblom D, Sartipy U. Survival and quality of life in cardiac surgery patients with prolonged intensive care. Ann Thorac Surg. 2010;89(2):490–5.

    Article  Google Scholar 

  4. Turrentine FE, Wang H, Simpson VB, Jones RS. Surgical risk factors, morbidity, and mortality in elderly patients. J Am Coll Surg. 2006;203(6):865–77.

    Article  Google Scholar 

  5. Milone M, Di Minno MN, Bifulco G, et al. Diagnostic value of abdominal free air detection on a plain chest radiograph in the early postoperative period: a prospective study in 648 consecutive patients who have undergone abdominal surgery. J Gastrointest Surg. 2013;17(9):1673–82.

    Article  Google Scholar 

  6. Earls JP, Dachman AH, Colon E, Garrett MG, Molloy M. Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography. AJR Am J Roentgenol. 1993;161(4):781–5.

    Article  CAS  Google Scholar 

  7. Gayer G, Jonas T, Apter S, Amitai M, Shabtai M, Hertz M. Postoperative pneumoperitoneum as detected by CT: prevalence, duration, and relevant factors affecting its possible significance. Abdom Imaging. 2000;25(3):301–5.

    Article  CAS  Google Scholar 

  8. Chapman BC, McIntosh KE, Jones EL, Wells D, Stiegmann GV, Robinson TN. Postoperative pneumoperitoneum: is it normal or pathologic? J Surg Res. 2015;197(1):107–11.

    Article  Google Scholar 

  9. Malgras B, Place V, Dohan A, et al. Natural history of pneumoperitoneum after laparotomy: findings on multidetector-row computed tomography. World J Surg. 2017;41(1):56–63.

    Article  Google Scholar 

  10. Feingold DL, Widmann WD, Calhoun SK, et al. Persistent post-laparoscopy pneumoperitoneum. Surg Endosc. 2003;17(2):296–9.

    Article  CAS  Google Scholar 

  11. Draper K, Jefson R, Jongeward R Jr, McLeod M. Duration of postlaparoscopic pneumoperitoneum. Surg Endosc. 1997;11(8):809–11.

    Article  CAS  Google Scholar 

  12. Solis CV, Chang Y, De Moya MA, Velmahos GC, Fagenholz PJ. Free air on plain film: do we need a computed tomography too? J Emerg Trauma Shock. 2014;7(1):3–8.

    Article  Google Scholar 

  13. Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr. 1992;16(5):713–6.

    Article  CAS  Google Scholar 

  14. Soreide K, Thorsen K, Harrison EM, et al. Perforated peptic ulcer. Lancet. 2015;386(10000):1288–98.

    Article  Google Scholar 

  15. Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK. A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med. 1989;320(15):970–3.

    Article  CAS  Google Scholar 

  16. Buck DL, Vester-Andersen M, Moller MH. Danish clinical register of emergency S. Surgical delay is a critical determinant of survival in perforated peptic ulcer. Br J Surg. 2013;100(8):1045–9.

    Article  CAS  Google Scholar 

  17. Sallinen VJ, Mentula PJ, Leppaniemi AK. Nonoperative management of perforated diverticulitis with extraluminal air is safe and effective in selected patients. Dis Colon Rectum. 2014;57(7):875–81.

    Article  Google Scholar 

  18. Langell JT, Mulvihill SJ. Gastrointestinal perforation and the acute abdomen. Med Clin North Am. 2008;92(3):599–625, viii–ix.

    Article  Google Scholar 

  19. De’Angelis N, Esposito F, Memeo R, et al. Emergency abdominal surgery after solid organ transplantation: a systematic review. World J Emerg Surg. 2016;11(1):43.

    Article  Google Scholar 

  20. Larson ES, Khalil HA, Lin AY, et al. Diverticulitis occurs early after lung transplantation. J Surg Res. 2014;190(2):667–71.

    Article  Google Scholar 

  21. Beaver TM, Fullerton DA, Zamora MR, et al. Colon perforation after lung transplantation. Ann Thorac Surg. 1996;62(3):839–43.

    Article  CAS  Google Scholar 

  22. Reshef A, Stocchi L, Kiran RP, et al. Case-matched comparison of perioperative outcomes after surgical treatment of sigmoid diverticulitis in solid organ transplant recipients versus immunocompetent patients. Color Dis. 2012;14(12):1546–52.

    Article  CAS  Google Scholar 

  23. Blum CA, Selander C, Ruddy JM, Leon S. The incidence and clinical significance of pneumoperitoneum after percutaneous endoscopic gastrostomy: a review of 722 cases. Am Surg. 2009;75(1):39–43.

    PubMed  Google Scholar 

  24. Nazarian A, Cross W, Kowdley GC. Pneumoperitoneum after percutaneous endoscopic gastrostomy among adults in the intensive care unit: incidence, predictive factors, and clinical significance. Am Surg. 2012;78(5):591–4.

    PubMed  Google Scholar 

  25. Alley JB, Corneille MG, Stewart RM, Dent DL. Pneumoperitoneum after percutaneous endoscopic gastrostomy in patients in the intensive care unit. Am Surg. 2007;73(8):765–7; discussion 768

    PubMed  Google Scholar 

  26. Kiefer T, Schenk U, Weber J, Hubel E, Kuhlmann U. Incidence and significance of pneumoperitoneum in continuous ambulatory peritoneal dialysis. Am J Kidney Dis. 1993;22(1):30–5.

    Article  CAS  Google Scholar 

  27. Kallmeyer IJ, Collard CD, Fox JA, Body SC, Shernan SK. The safety of intraoperative transesophageal echocardiography: a case series of 7200 cardiac surgical patients. Anesth Analg. 2001;92(5):1126–30.

    Article  CAS  Google Scholar 

  28. Hilberath JN, Oakes DA, Shernan SK, Bulwer BE, D'Ambra MN, Eltzschig HK. Safety of transesophageal echocardiography. J Am Soc Echocardiogr. 2010;23(11):1115–27; quiz 1220–1

    Article  Google Scholar 

  29. Cocorullo G, Mirabella A, Falco N, et al. An investigation of bedside laparoscopy in the ICU for cases of non-occlusive mesenteric ischemia. World J Emerg Surg. 2017;12:4.

    Article  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Surgery, University of Chicago, Chicago, IL, USA

    Robert Keskey & John Alverdy

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  1. Robert Keskey
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  2. John Alverdy
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Correspondence to John Alverdy .

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Editors and Affiliations

  1. University of Chicago Medicine, Chicago, IL, USA

    Vassyl A. Lonchyna

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Keskey, R., Alverdy, J. (2019). Free Air in the Postoperative CT Patient: Observe or Operate?. In: Lonchyna, V. (eds) Difficult Decisions in Cardiothoracic Critical Care Surgery. Difficult Decisions in Surgery: An Evidence-Based Approach. Springer, Cham. https://doi.org/10.1007/978-3-030-04146-5_39

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  • DOI: https://doi.org/10.1007/978-3-030-04146-5_39

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  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-04145-8

  • Online ISBN: 978-3-030-04146-5

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