Postoperative Pneumoperitoneum:
an
Unusual Etiology
MOISES TENEMBAUM, M.D., JOEL J. BAUER, M.D., IRWIN M. GELERNT, M.D., ISADORE KREEL, M.D., ARTHUR H. AUFSES, JR., M.D.
Although postoperative pneumoperitoneum is a common finding, it is particularly disturbing when there is an increase in the amount of postoperative pneumoperitoneum or when the radiographic finding of pneumoperitoneum is accompanied by such physical findings as increased abdominal tenderness, peritoneal signs or paralytic ileus. Four patients operated upon at the Mount Sinai Hospital are presented. All patients underwent abdominal surgery for treatment of some form of inflammatory bowel disease and all were receiving systemic corticosteroids in the postoperative period. Abdominal findings of tenderness, ileus and peritoneal irritation developed shortly after the removal of Penrose drains in the postoperative period. Pneumoperitoneum was confirmed by abdominal roentgenographs. The first patient in this group underwent a laparotomy with essentially negative findings other than a freely open drain tract. The subsequent three patients were managed by close observation and frequent abdominal radiographs. These three patients had contrast roentgenographic studies of the upper gastrointestinal tract to rule out perforation of a peptic ulcer, and in the patient upon whom reservoir ileostomy had been performed, a contrast study of the reservoir was perforined. All patients recovered fully with this management and there were no sequelae. The mechanism for the appearance of pneumoperitoneum after removal of drains, particularly when the patient is receiving systemic corticosteroids, is discussed. Emphasis is placed on the need to consider and rule out perforation of a hollow viscus in this situation before accepting drain removal as the sole cause of postoperative pneumoperitoneum.
TrHE PRESENCE OF free air in the peritoneal cavity in patients who have not had recent invasive abdominal procedures is usually indicative of a perforated hollow viscus and is almost always an indication for prompt operative intervention. The radiographic finding of air following abdominal surgery is common but not invariable; it could be demonstrated in approximately 77% of patients.3 Some authors'2 have suggested that it is present in all patients after abdominal surgery. A problem which occasionally confronts the surgeon is the roentgenographic finding of large amounts of intraperitoneal air in the postoperative patient. This finding is disturbing, particularly if abdominal roentgenographs earlier in the postoperative period have Submitted for publication: March 8, 1978.
From the Department of Surgery, Mount Sinai School of Medicine, New York, New York
shown lesser or total absence of free air or if signs of peritonitis are present. It is imperative that perforation of a hollow intra-abdominal viscus be considered, and every effort be made to confirm or rule out this diagnosis. Several causes of pneumoperitoneum in the postoperative patient do not require operative intervention for their treatment. These entities must be considered when evaluating such a patient. This report describes four patients in whom late massive postoperative pneumoperitoneum occurred immediately after intra-abdominal Penrose drains were removed. All four patients were receiving systemic corticosteroids for several months prior to surgery and continued to receive maintenance doses during the postoperative period. Case Reports Case 1. B.G., a 16-year-old boy, underwent a total protocolectomy and terminal ileostomy for chronic ulcerative colitis. The patient had been treated with 40 mg Prednisone, by mouth every other day for several months prior to surgery. The procedure was performed through a midline abdominal incision and Penrose drains were brought out through right and left lateral stab wounds. Postoperatively, the patient was given intravenous and then oral corticosteroids. The patient had an uncomplicated postoperative course until the thirteenth postoperative day when the right drain was removed. Several hours later, the patient complained of diffuse abdominal pain. The temperature was elevated to 38.60. The abdomen was moderately distended and there was significant diffuse abdominal tenderness. Bowel sounds were present but hypoactive. The wound was clean and was healing well. Blood count revealed 37.000 white blood cells/mm3 with a marked shift to the left. Abdominal roentgenographs showed massive pneumoperitoneum. Four hours after the onset of the episode, with no improvement in the abdominal findings, the patient was explored with the presumed diagnosis of a perforated hollow viscus, (most likely due to peptic ulcer). Upon opening the abdomen, it was noted that, at the site where the Penrose drain had been placed, there was a straight and freely open tract. Thorough exploration of the abdominal and pelvic organs failed to reveal any other pathology to account for the free intraperitoneal air. The abdomen was lavaged and closed. The postoperative course was uncompli-
0003-4932/78/1200/0769 $00.70 © J. B. Lippincott Company
769
770
Ann. Surg.
TENEMBAUM AND OTHERS
December 1978
venously, and then orally during the postoperative period. The postoperative course was uneventful until the fourteenth postoperative day when the patient felt very weak and had diffuse abdominal pain. This occurred approximately one left sided drain was removed. The rectal 36.70.
The abdomen
tenderness. There
hours
were no
functioning.
The wound
was
quadrant
peritoneal signs. Bowel sounds
was
after
temperature
soft with very mild left upper
was
present and the ileostomy and
three
was
were clean
healing well.
Abdominal roentgenographs revealed large amounts of free air under
the
left
hemidiaphragm
1).
(Fig.
gastrointestinal series (Fig. 2) and
a
A
contrast
Gastrografin
upper
study of the ileal
reservoir (Fig. 3) were performed. These studies failed to reveal extravasation from either the upper gastrointestinal tract or the reservoir ileostomy. It was assumed that the free air was secondary to the removal of the drains. Oral intake
was
stopped and
intravenous fluids instituted. The ileostomy continued to function
normally.
On the seventeenth
postoperative day
the
patient
asymptomatic. Two days later, oral intake X-rays showed
was
discharged
a
gradual decrease in
on
was
was
completely
reinstituted.
the amount of air and she
the twenty-eighth postoperative day in very
good condition. Case 4. C.M., a 25-year-old woman, underwent a subtotal colectomy and ileostomy for granulomatous ileocolitis. The patient had been receiving 20 mg/day Prednisone prior to operation. The sigmoid stump was closed with three layers of sutures, and Penrose drains were brought out through a stab wound in the left FIG. 1. Upright roentgenograph of chest demonstrating presence of free air under both
cated and the tive
patient
hemidiaphragms (arrows).
was
discharged
on
the thirty-first postopera-
day.
Case 2. C.C. was a 57-year-old man with known ulcerative colitis of 15 years duration who was receiving 20 mg Prednisone per day prior to surgery. He underwent a total proctocolectomy with terminal ileostomy. The procedure was performed through a midline incision. Penrose drains were brought out through separate right and left lateral stab
wounds. Intravenous and then oral cortico-
were administered postoperatively. course was unremarkable until the eleventh when Penrose drains were removed from the
steroids
The
postoperative
postoperative day right and left sides of the abdomen. On that evening, the patient complained of left upper quadrant abdominal pain. Temperature was elevated to 38.60. The abdomen was soft but distended; there was mild tenderness in the left upper and lower quadrants. There was no guarding or rebound tenderness. The ileostomy output had ceased and bowel sounds were not audible. Abdominal roentgenographs showed large amounts of free air under both hemidiaphragms and air-fluid levels in the small bowel. Intravenous fluids and antibiotics were administered. An upper gastrointestinal x-ray using Gastrografing failed to reveal an ulcer or perforation. During the next few days, the abdomen became less distended and the tenderness subsided. On the fifteenth postoperative day, oral feedings were reinstituted. The amount of free air gradually decreased and on the twenty-fifth postoperative day he was discharged in good condition. Case 3. R.R., an 18-year-old woman with a three year history of chronic ulcerative colitis, underwent an elective total proctocolectomy and continent reservoir ileostomy. She had been
.
receiv-
ing methylprednisolone for several months prior to surgery. The procedure was performed through a midline incision. Penrose drains were brought out through separate right and left lateral stab
FIG. 2. Upper gastrointestinal series using gastrografin which
wounds. Maintenance corticosteroids were administered intra-
demonstrates no extravasation from stomach or duodenum.
VOl. 188 . NO. 6
POSTOPERATIVE PNEUMOPERITONEUM
771
lower quadrant. The patient received maintenance corticosteroids postoperatively. The postoperative course was uneventful until the tenth postoperative day when the last drain was removed. That afternoon, the patient began to complain of diffuse abdominal discomfort and bilateral shoulder pain when standing. Physical examination revealed the patient to be in no acute distress. There was mild abdominal distension and diffuse tympany. The wound was clean and well healed. There was no tenderness and the ileostomy stoma was functioning normally. Vital signs were all normal. Abdominal x-rays revealed massive pneumoperitoneum. Upper gastrointestinal series using Gastrografin revealed no extravasation of contrast material. The patient was placed on intravenous fluids and antibiotics, and oral feedings were stopped. Her abdomen became less distended and her ileostomy continued to function normally. After 48 hours, oral feedings were reinstituted. X-rays showed a gradual decrease in the amount of free air, and the patient was discharged five days after the episode occurred.
Discussion
Postoperative pneumoperitoneum is a common finding. Its incidence ranges between 58 and 77% following intra-abdominal operations.3'5 Any loss of the integrity of the peritoneum including small and transient openings as in inguinal herniorrhaphies or stab wounds may result in a pneumoperitoneum.7 Postoperative intraperitoneal air may be present for a variable period of time after operation. The duration of the pneumoperitoneum is proportional to the amount of air trapped at the time of abdominal closure. From 100 to 500 cc of air may persist for approximately one week before complete absorption occurs. An average postoperative pneumoperitoneum of 500 to 1000 cc may last for approximately ten days.3 Wiot14 presented a case in which absorption was not complete until tI ie thirtyeighth postoperative day. The presence of what appears to be free air in the subdiaphragmatic space may, in fact, be a sub iaphragmatic abscess with an air fluid level. In addition to the pneumoperitoneum seen postoperatively and that associated with perforation of hollow organs, pneumoperitoneum has also been reported in association with the use of mechanical ventilatory support,12 especially when positive end expiratory pressure (PEEP) is used.12'8 It has also been reported following abdominal paracentesis and peritoneal dialysis.6 At least three cases of free intraperitoneal air entering through drain tracts have been recorded prior to this report.5'0'4 The association of pneumoperitoneum with the removal of intra-abdominal drains and the chronic administration of steroids, as in our four patients, has not been previously reported. It is interesting that all four patients presented in this report were symptomatic, and all complained of abdominal pain to some degree. Three of the four patients were distended with varying degrees of paralytic ileus. The temperature was elevated in two of them.
FIG. 3. Contrast study of ileal reservoir which demonstrates no extravasation (hollow arrow denotes catheter in reservoir).
The four patients reported were all receiving large doses of maintenance corticosteroids postoperatively. It is well known that the anti-inflammatory corticosteroids decrease the rate of healing of surgical wounds."1 The inhibitory effect on wound healing occurs especially when the corticosteroids are given in moderately large doses and within the first two or three days after surgery13 as was the case in our four patients. Corticosteroids will delay the appearance of almost all elements of wound healing. If steroids are instituted later in the postoperative period (four days or more after surgery), the effect on the healing process will be negligible. Anti-inflammatory steroids act by inhibiting the inflammatory phase of the healing process. The action can be explained in part by the effect that steroids have on lysosomal physiology. They increase the integrity of the lysosome,9 whose enzymes are known to have a prominent role in the inflammatory process. Drains are usually sealed off from the peritoneal cavity in a matter of hours or days following their placement.5 When they are removed, the presence of a fibrinous response and the fact that stab wounds are obliquely placed through the tissue layers, usually facilitate almost immediate closure of the drain tracts. In the cases presented in this report, it is likely that by
772
TENEMBAUM AND OTHERS
inhibiting the fibrinous and inflammatory response, the corticosteroids prevented the normal sealing of the drain tracts from the free peritoneal cavity or its subsequent obliteration when the drains were removed. When a postoperative patient develops abdominal pain and findings consistent with pneumoperitoneum, the burden is upon the surgeon to prove that perforation of a hollow viscus has not occurred. This is especially true in patients receiving corticosteroids where perforation of peptic ulcers, colonic diverticula and dehiscence of anastomoses is more common. It would be a gross error to assume that the pneumoperitoneum is secondary to drain removal before excluding the diagnosis of a perforated viscus. In three of the four patients reported here, radiographic contrast studies of the upper gastrointestinal tract were performed. In one patient, a contrast study of the ileal reservoir was performed as well. Only in the first patient, B.G., encountered among these four was no contrast study performed, and this patient's abdomen was promptly explored.
References 1. Bannen, J. E.: Postoperative Pneumoperitoneum. Br. J. Radiol., 17:119, 1944.
Ann. Surg. * December 1978
2. Bannen, J. E.: Investigation of Free Gas in the Peritoneal Cavity. Br. J. Radiol., 18:390, 1945. 3. Bevan, P. G.: Incidence of Postoperative Pneumoperitoneum and its Significance. Br. Med. J., 2:605, 1961. 4. Bryant, L. R., Hayden, G. B. and Altermeir, W. A.: An Unusual Complication of Radical Hysterectomy and Pelvic Lymphadenectomy. Surg. Gynecol. Obstet., 113:455, 1961. 5. Bryant, L. R., Wiott, J. R. and R. Kloecker, R. J.: A Study of the Factors Affecting the Incidence and Duration of Postoperative Pneumoperitoneum. Surg. Gynecol. Obstet., 117: 145, 1963. 6. Chandler, J. G., Berk, R. N. and Golden, G. T.: Misleading Pneumoperitoneum. Surg. Gynecol. Obstet., 144:163, 1977. 7. Cunningham, J. J.: Postoperative Spontaneous Pneumoperitoneum. Am. J. Surg., 73:725, 1947. 8. Egan, M. and Boutros, A.: Pneumoperitoneum Following Tension Pneumothorax: Report of Two Cases. Crit. Care Med., 3:170, 1975. 9. Ehrilich, H. P. and Hunt, T. K.: Effects of Cortisone and Vitamine A on Wound Healing. Ann. Surg., 167:324, 1969. 10. Heslin, J. and Malt, R. A.: Progressive Postoperative Pneumoperitoneum. Air Entering Through Drain Sites. Am. J. Roentgenol., 92:1166, 1964. 11. Howes, E. L., Plotz, C. M., Blunt, J. W. and Ragan, C.: Retardation of Wound Healing by Cortisone. Surgery, 28: 177, 1950. 12. Stringfield, J. T., III, Graham, J. P., Watts, C. M., et al.: Pneumoperitoneum: A Complication of Mechanical Ventilation. J.A.M.A., 235:744, 1976. 13. Sandberg, N.: Time Relationship Between Administration of Cortisone and Wound Healing in Rats. Acta Chir. Scand., 127:446, 1964. 14. Wiot, J. F., Benton, C. and McCalister, W. H.: Postoperative Pneumoperitoneum in Children. Radiology, 89:285, 1967.
Announcement The appearance of the code at the bottom of the first page of an article in this journal indicates the copyright owner's consent that copies of the article may be made for personal or internal use, or for personal or internal use of specific clients. This consent is given on the condition, however, that the copier pay the stated per-copy fee through the Copyright Clearance Center Inc., P.O. Box 765, Schenectady, N.Y. 12301, for copying beyond that permitted by Sections 107 or 108 of the U.S. Copyright Law. This consent does not extend to other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale.
an
Unusual Etiology
MOISES TENEMBAUM, M.D., JOEL J. BAUER, M.D., IRWIN M. GELERNT, M.D., ISADORE KREEL, M.D., ARTHUR H. AUFSES, JR., M.D.
Although postoperative pneumoperitoneum is a common finding, it is particularly disturbing when there is an increase in the amount of postoperative pneumoperitoneum or when the radiographic finding of pneumoperitoneum is accompanied by such physical findings as increased abdominal tenderness, peritoneal signs or paralytic ileus. Four patients operated upon at the Mount Sinai Hospital are presented. All patients underwent abdominal surgery for treatment of some form of inflammatory bowel disease and all were receiving systemic corticosteroids in the postoperative period. Abdominal findings of tenderness, ileus and peritoneal irritation developed shortly after the removal of Penrose drains in the postoperative period. Pneumoperitoneum was confirmed by abdominal roentgenographs. The first patient in this group underwent a laparotomy with essentially negative findings other than a freely open drain tract. The subsequent three patients were managed by close observation and frequent abdominal radiographs. These three patients had contrast roentgenographic studies of the upper gastrointestinal tract to rule out perforation of a peptic ulcer, and in the patient upon whom reservoir ileostomy had been performed, a contrast study of the reservoir was perforined. All patients recovered fully with this management and there were no sequelae. The mechanism for the appearance of pneumoperitoneum after removal of drains, particularly when the patient is receiving systemic corticosteroids, is discussed. Emphasis is placed on the need to consider and rule out perforation of a hollow viscus in this situation before accepting drain removal as the sole cause of postoperative pneumoperitoneum.
TrHE PRESENCE OF free air in the peritoneal cavity in patients who have not had recent invasive abdominal procedures is usually indicative of a perforated hollow viscus and is almost always an indication for prompt operative intervention. The radiographic finding of air following abdominal surgery is common but not invariable; it could be demonstrated in approximately 77% of patients.3 Some authors'2 have suggested that it is present in all patients after abdominal surgery. A problem which occasionally confronts the surgeon is the roentgenographic finding of large amounts of intraperitoneal air in the postoperative patient. This finding is disturbing, particularly if abdominal roentgenographs earlier in the postoperative period have Submitted for publication: March 8, 1978.
From the Department of Surgery, Mount Sinai School of Medicine, New York, New York
shown lesser or total absence of free air or if signs of peritonitis are present. It is imperative that perforation of a hollow intra-abdominal viscus be considered, and every effort be made to confirm or rule out this diagnosis. Several causes of pneumoperitoneum in the postoperative patient do not require operative intervention for their treatment. These entities must be considered when evaluating such a patient. This report describes four patients in whom late massive postoperative pneumoperitoneum occurred immediately after intra-abdominal Penrose drains were removed. All four patients were receiving systemic corticosteroids for several months prior to surgery and continued to receive maintenance doses during the postoperative period. Case Reports Case 1. B.G., a 16-year-old boy, underwent a total protocolectomy and terminal ileostomy for chronic ulcerative colitis. The patient had been treated with 40 mg Prednisone, by mouth every other day for several months prior to surgery. The procedure was performed through a midline abdominal incision and Penrose drains were brought out through right and left lateral stab wounds. Postoperatively, the patient was given intravenous and then oral corticosteroids. The patient had an uncomplicated postoperative course until the thirteenth postoperative day when the right drain was removed. Several hours later, the patient complained of diffuse abdominal pain. The temperature was elevated to 38.60. The abdomen was moderately distended and there was significant diffuse abdominal tenderness. Bowel sounds were present but hypoactive. The wound was clean and was healing well. Blood count revealed 37.000 white blood cells/mm3 with a marked shift to the left. Abdominal roentgenographs showed massive pneumoperitoneum. Four hours after the onset of the episode, with no improvement in the abdominal findings, the patient was explored with the presumed diagnosis of a perforated hollow viscus, (most likely due to peptic ulcer). Upon opening the abdomen, it was noted that, at the site where the Penrose drain had been placed, there was a straight and freely open tract. Thorough exploration of the abdominal and pelvic organs failed to reveal any other pathology to account for the free intraperitoneal air. The abdomen was lavaged and closed. The postoperative course was uncompli-
0003-4932/78/1200/0769 $00.70 © J. B. Lippincott Company
769
770
Ann. Surg.
TENEMBAUM AND OTHERS
December 1978
venously, and then orally during the postoperative period. The postoperative course was uneventful until the fourteenth postoperative day when the patient felt very weak and had diffuse abdominal pain. This occurred approximately one left sided drain was removed. The rectal 36.70.
The abdomen
tenderness. There
hours
were no
functioning.
The wound
was
quadrant
peritoneal signs. Bowel sounds
was
after
temperature
soft with very mild left upper
was
present and the ileostomy and
three
was
were clean
healing well.
Abdominal roentgenographs revealed large amounts of free air under
the
left
hemidiaphragm
1).
(Fig.
gastrointestinal series (Fig. 2) and
a
A
contrast
Gastrografin
upper
study of the ileal
reservoir (Fig. 3) were performed. These studies failed to reveal extravasation from either the upper gastrointestinal tract or the reservoir ileostomy. It was assumed that the free air was secondary to the removal of the drains. Oral intake
was
stopped and
intravenous fluids instituted. The ileostomy continued to function
normally.
On the seventeenth
postoperative day
the
patient
asymptomatic. Two days later, oral intake X-rays showed
was
discharged
a
gradual decrease in
on
was
was
completely
reinstituted.
the amount of air and she
the twenty-eighth postoperative day in very
good condition. Case 4. C.M., a 25-year-old woman, underwent a subtotal colectomy and ileostomy for granulomatous ileocolitis. The patient had been receiving 20 mg/day Prednisone prior to operation. The sigmoid stump was closed with three layers of sutures, and Penrose drains were brought out through a stab wound in the left FIG. 1. Upright roentgenograph of chest demonstrating presence of free air under both
cated and the tive
patient
hemidiaphragms (arrows).
was
discharged
on
the thirty-first postopera-
day.
Case 2. C.C. was a 57-year-old man with known ulcerative colitis of 15 years duration who was receiving 20 mg Prednisone per day prior to surgery. He underwent a total proctocolectomy with terminal ileostomy. The procedure was performed through a midline incision. Penrose drains were brought out through separate right and left lateral stab
wounds. Intravenous and then oral cortico-
were administered postoperatively. course was unremarkable until the eleventh when Penrose drains were removed from the
steroids
The
postoperative
postoperative day right and left sides of the abdomen. On that evening, the patient complained of left upper quadrant abdominal pain. Temperature was elevated to 38.60. The abdomen was soft but distended; there was mild tenderness in the left upper and lower quadrants. There was no guarding or rebound tenderness. The ileostomy output had ceased and bowel sounds were not audible. Abdominal roentgenographs showed large amounts of free air under both hemidiaphragms and air-fluid levels in the small bowel. Intravenous fluids and antibiotics were administered. An upper gastrointestinal x-ray using Gastrografing failed to reveal an ulcer or perforation. During the next few days, the abdomen became less distended and the tenderness subsided. On the fifteenth postoperative day, oral feedings were reinstituted. The amount of free air gradually decreased and on the twenty-fifth postoperative day he was discharged in good condition. Case 3. R.R., an 18-year-old woman with a three year history of chronic ulcerative colitis, underwent an elective total proctocolectomy and continent reservoir ileostomy. She had been
.
receiv-
ing methylprednisolone for several months prior to surgery. The procedure was performed through a midline incision. Penrose drains were brought out through separate right and left lateral stab
FIG. 2. Upper gastrointestinal series using gastrografin which
wounds. Maintenance corticosteroids were administered intra-
demonstrates no extravasation from stomach or duodenum.
VOl. 188 . NO. 6
POSTOPERATIVE PNEUMOPERITONEUM
771
lower quadrant. The patient received maintenance corticosteroids postoperatively. The postoperative course was uneventful until the tenth postoperative day when the last drain was removed. That afternoon, the patient began to complain of diffuse abdominal discomfort and bilateral shoulder pain when standing. Physical examination revealed the patient to be in no acute distress. There was mild abdominal distension and diffuse tympany. The wound was clean and well healed. There was no tenderness and the ileostomy stoma was functioning normally. Vital signs were all normal. Abdominal x-rays revealed massive pneumoperitoneum. Upper gastrointestinal series using Gastrografin revealed no extravasation of contrast material. The patient was placed on intravenous fluids and antibiotics, and oral feedings were stopped. Her abdomen became less distended and her ileostomy continued to function normally. After 48 hours, oral feedings were reinstituted. X-rays showed a gradual decrease in the amount of free air, and the patient was discharged five days after the episode occurred.
Discussion
Postoperative pneumoperitoneum is a common finding. Its incidence ranges between 58 and 77% following intra-abdominal operations.3'5 Any loss of the integrity of the peritoneum including small and transient openings as in inguinal herniorrhaphies or stab wounds may result in a pneumoperitoneum.7 Postoperative intraperitoneal air may be present for a variable period of time after operation. The duration of the pneumoperitoneum is proportional to the amount of air trapped at the time of abdominal closure. From 100 to 500 cc of air may persist for approximately one week before complete absorption occurs. An average postoperative pneumoperitoneum of 500 to 1000 cc may last for approximately ten days.3 Wiot14 presented a case in which absorption was not complete until tI ie thirtyeighth postoperative day. The presence of what appears to be free air in the subdiaphragmatic space may, in fact, be a sub iaphragmatic abscess with an air fluid level. In addition to the pneumoperitoneum seen postoperatively and that associated with perforation of hollow organs, pneumoperitoneum has also been reported in association with the use of mechanical ventilatory support,12 especially when positive end expiratory pressure (PEEP) is used.12'8 It has also been reported following abdominal paracentesis and peritoneal dialysis.6 At least three cases of free intraperitoneal air entering through drain tracts have been recorded prior to this report.5'0'4 The association of pneumoperitoneum with the removal of intra-abdominal drains and the chronic administration of steroids, as in our four patients, has not been previously reported. It is interesting that all four patients presented in this report were symptomatic, and all complained of abdominal pain to some degree. Three of the four patients were distended with varying degrees of paralytic ileus. The temperature was elevated in two of them.
FIG. 3. Contrast study of ileal reservoir which demonstrates no extravasation (hollow arrow denotes catheter in reservoir).
The four patients reported were all receiving large doses of maintenance corticosteroids postoperatively. It is well known that the anti-inflammatory corticosteroids decrease the rate of healing of surgical wounds."1 The inhibitory effect on wound healing occurs especially when the corticosteroids are given in moderately large doses and within the first two or three days after surgery13 as was the case in our four patients. Corticosteroids will delay the appearance of almost all elements of wound healing. If steroids are instituted later in the postoperative period (four days or more after surgery), the effect on the healing process will be negligible. Anti-inflammatory steroids act by inhibiting the inflammatory phase of the healing process. The action can be explained in part by the effect that steroids have on lysosomal physiology. They increase the integrity of the lysosome,9 whose enzymes are known to have a prominent role in the inflammatory process. Drains are usually sealed off from the peritoneal cavity in a matter of hours or days following their placement.5 When they are removed, the presence of a fibrinous response and the fact that stab wounds are obliquely placed through the tissue layers, usually facilitate almost immediate closure of the drain tracts. In the cases presented in this report, it is likely that by
772
TENEMBAUM AND OTHERS
inhibiting the fibrinous and inflammatory response, the corticosteroids prevented the normal sealing of the drain tracts from the free peritoneal cavity or its subsequent obliteration when the drains were removed. When a postoperative patient develops abdominal pain and findings consistent with pneumoperitoneum, the burden is upon the surgeon to prove that perforation of a hollow viscus has not occurred. This is especially true in patients receiving corticosteroids where perforation of peptic ulcers, colonic diverticula and dehiscence of anastomoses is more common. It would be a gross error to assume that the pneumoperitoneum is secondary to drain removal before excluding the diagnosis of a perforated viscus. In three of the four patients reported here, radiographic contrast studies of the upper gastrointestinal tract were performed. In one patient, a contrast study of the ileal reservoir was performed as well. Only in the first patient, B.G., encountered among these four was no contrast study performed, and this patient's abdomen was promptly explored.
References 1. Bannen, J. E.: Postoperative Pneumoperitoneum. Br. J. Radiol., 17:119, 1944.
Ann. Surg. * December 1978
2. Bannen, J. E.: Investigation of Free Gas in the Peritoneal Cavity. Br. J. Radiol., 18:390, 1945. 3. Bevan, P. G.: Incidence of Postoperative Pneumoperitoneum and its Significance. Br. Med. J., 2:605, 1961. 4. Bryant, L. R., Hayden, G. B. and Altermeir, W. A.: An Unusual Complication of Radical Hysterectomy and Pelvic Lymphadenectomy. Surg. Gynecol. Obstet., 113:455, 1961. 5. Bryant, L. R., Wiott, J. R. and R. Kloecker, R. J.: A Study of the Factors Affecting the Incidence and Duration of Postoperative Pneumoperitoneum. Surg. Gynecol. Obstet., 117: 145, 1963. 6. Chandler, J. G., Berk, R. N. and Golden, G. T.: Misleading Pneumoperitoneum. Surg. Gynecol. Obstet., 144:163, 1977. 7. Cunningham, J. J.: Postoperative Spontaneous Pneumoperitoneum. Am. J. Surg., 73:725, 1947. 8. Egan, M. and Boutros, A.: Pneumoperitoneum Following Tension Pneumothorax: Report of Two Cases. Crit. Care Med., 3:170, 1975. 9. Ehrilich, H. P. and Hunt, T. K.: Effects of Cortisone and Vitamine A on Wound Healing. Ann. Surg., 167:324, 1969. 10. Heslin, J. and Malt, R. A.: Progressive Postoperative Pneumoperitoneum. Air Entering Through Drain Sites. Am. J. Roentgenol., 92:1166, 1964. 11. Howes, E. L., Plotz, C. M., Blunt, J. W. and Ragan, C.: Retardation of Wound Healing by Cortisone. Surgery, 28: 177, 1950. 12. Stringfield, J. T., III, Graham, J. P., Watts, C. M., et al.: Pneumoperitoneum: A Complication of Mechanical Ventilation. J.A.M.A., 235:744, 1976. 13. Sandberg, N.: Time Relationship Between Administration of Cortisone and Wound Healing in Rats. Acta Chir. Scand., 127:446, 1964. 14. Wiot, J. F., Benton, C. and McCalister, W. H.: Postoperative Pneumoperitoneum in Children. Radiology, 89:285, 1967.
Announcement The appearance of the code at the bottom of the first page of an article in this journal indicates the copyright owner's consent that copies of the article may be made for personal or internal use, or for personal or internal use of specific clients. This consent is given on the condition, however, that the copier pay the stated per-copy fee through the Copyright Clearance Center Inc., P.O. Box 765, Schenectady, N.Y. 12301, for copying beyond that permitted by Sections 107 or 108 of the U.S. Copyright Law. This consent does not extend to other kinds of copying, such as copying for general distribution, for advertising or promotional purposes, for creating new collective works, or for resale.
