Percutaneous Treatment of Massive Pneumoperitoneum Following Reintubation After Coronary Artery Bypass Surgery

Abstract

The aim of this study is to present a percutaneous treatment option for a patient with massive pneumoperitoneum following intubation after coronary artery bypass surgery. After coronary artery bypass surgery, a 74-year-old woman had prolonged endotracheal intubation due to hypoxia associated with pneumonia. On postoperative day seven, she was reintubated with inadequate ventilation leading to hypercapnia due to blockage of the endotracheal tube. Shortly after intubation, the patient was hypotensive, tachycardic, and hypoxic. The breath sound was absent on the right hemithorax, and the abdomen was distended. The chest x-ray showed a right-sided tension pneumothorax. A chest tube was placed on suction to the right hemithorax immediately. The computed tomography scan showed a massive pneumoperitoneum without free fluid in the abdomen. Air evacuation from the peritoneum was performed using a 7 French percutaneous venous catheter and 50 cc syringe. As a practical technique to see air bubbles puffing out from the peritoneal cavity, we connected the sterile water-filled syringe to the line upwards. After the air evacuation, the abdomen was softened and non-distended. Arterial blood gas sample and peak airway pressure became normal. To avoid unnecessary surgical procedures, we need to recognize whether pneumoperitoneum is surgical or not. In non-surgical pneumoperitoneum, the less invasive air evacuation techniques may be faster, more practical, and as effective as placing an intraperitoneal tube or laparoscopy. The percutaneous drainage techniques should be tried as a first-line treatment in pneumoperitoneum without symptoms and signs of peritonitis.

Keywords

• Pneumoperitoneum
• minimally invasive surgical procedures
• perioperative care

References

1. 1. Williams NM, Watkin DF. Spontaneous pneumoperitoneum and other nonsurgical causes of intraperitoneal free gas. Postgrad Med J 1997;73(863):531-7. [Crossref]
2. 2. Cecka F, Sotona O, Subrt Z. How to distinguish between surgical and non-surgical pneumoperitoneum? Signa Vitae 2014;9(1):9-15. [Crossref]
3. 3. Okamoto A, Nakao A, Matsuda K, Yamada T, Osako T, Sakata H, et al. Non-surgical pneumoperitoneum associated with mechanical ventilation. Acute Med Surg 2014;1(4):254-5. [Crossref]
4. 4. Mularski RA, Ciccolo ML, Rappaport WD. Nonsurgical causes of pneumoperitoneum. West J Med 1999;170:41-6.
5. 5. Patel RV, Kumar H, Patwardhan N, Antao B. Pneumoperitoneum: A rare air leak in an infant with bronchiolitis and high frequency oscillatory ventilation. BMJ Case Rep 2013:bcr2013010447. [Crossref]
6. 6. Elkholy KO, Akhtar H, Landa E, Malyshev Y, Sahni S. A case of pneumomediastinum and pneumoperitoneum with concurrent massive subcutaneous emphysema due to repositioning of a tracheostomy tube. Cureus 2019;11(1):e3881. [Crossref]