Management of Pneumoperitoneum: Role and Limits of Nonoperative Treatment

Abstract

Objectives: The aim of this study was to compare morbidity and mortality between nonoperative and operative treatment of pneumoperitoneum.

Background: Pneumoperitoneum is a potentially life-threatening condition that has been traditionally treated with surgical intervention. Adequately powered studies comparing treatment outcomes are lacking.

Methods: Chart review and computer-assisted abstraction were used to identify patients with pneumoperitoneum at 5 hospitals from 2010 to 2015. Patients with recent abdominal procedures or contained perforation were excluded. Patients were grouped by treatment modality: comfort measures only (CMO), nonoperative treatment, or operative intervention. CMO included only symptom-palliation, whereas nonoperative therapy included all interventions (antibiotics, peritoneal drains, resuscitation) excluding surgery. Outcomes were mortality, discharge disposition, and 30-day complications. Covariates included demographics, comorbidities, and acuity at presentation.

Results: Forty patients received CMO, 202 underwent nonoperative treatment, and 199 underwent operative intervention. CMO patients had 98% 30-day mortality. There was no difference in 30-day (P = 0.64) or 2-year mortality (P = 0.53) between patients treated nonoperatively and operatively. Compared with patients treated operatively, patients treated nonoperatively were more likely to have a colorectal source of pneumoperitoneum (37% vs 31%; P = 0.03). Using logistic regression, operative treatment was associated with increased dependence on enteral tube feeding or total parenteral nutrition [odds ratio (OR) 4.30, 95% confidence interval (CI), 1.99-9.29] and nonhome discharge (OR 3.61, 95% CI, 1.81-7.17). Among patients with clinical peritonitis, operative treatment was associated with reduced mortality (OR 0.17, 95% CI, 0.04-0.80).

Conclusions: Operative intervention is associated with reduced mortality in patients with pneumoperitoneum and peritonitis. In the absence of peritonitis, operative treatment is associated with increased morbidity and nonhome discharge.