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Ann Surg. 2019 Jul 23. doi: 10.1097/SLA.0000000000003492. [Epub ahead of print]

Management of Pneumoperitoneum: Role and Limits of Nonoperative Treatment.

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Department of Surgery, Massachusetts General Hospital, Boston, MA.
Department of Surgery, University of California San Diego, San Diego, CA.
Center for Surgery and Public Health, Brigham & Women's Hospital, Boston, MA.
Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, MA.
Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, MA.
Department of Surgery, Brigham and Women's Hospital, Boston, MA.



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


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


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.


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).


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.

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