Symptomatic pneumatosis intestinalis (including portal venous gas) after laparoscopic total colectomy

Abstract

The development of intramural intestinal gas may indicate a serious postoperative complication and therefore any radiological indication of such "pneumatosis intestinalis" (PI) in an unwell patient after surgery should put the clinical team on high-alert. However immediate recourse to relook laparotomy may not be always necessary and, further, in some cases may possibly accelerate the deterioration especially if it proves to be non-therapeutic. Careful and close clinical monitoring, as is described in this clinical report, may allow discriminative identification of those in whom this finding is in fact transient and therefore benign and who therefore can be successfully treated without operative re-intervention. We describe the presenting features and background scenario of PI early after laparoscopic total colectomy for medically refractory, severe ulcerative colitis and detail the critical postoperative decision pivots.

Keywords: Laparoscopic total colectomy; Pneumatosis intestinalis; Portal venous gas; Severe acute colitis; Ulcerative colitis.

Figure 1

Radiology of case one. (A) Preoperative plain film of abdomen showing no pneumatosis intestinalis in comparison to (B) postoperative computerized tomogram showing extensive intramural gas and (C) portal venous gas.

Figure 2

Radiology of case two. (A) and (B) comparative pre and postoperative plain radiology showing new and extensive intramural gas in the latter; C and D: Axial computerized tomograms taken on the 8^th postoperative day showing marked pneumatosis intestinalis.