Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Apr 14, 2020; 26(14): 1628-1637
Published online Apr 14, 2020. doi: 10.3748/wjg.v26.i14.1628
Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment
Masanori Gonda, Tatsuya Osuga, Yoshihiro Ikura, Kazunori Hasegawa, Kentaro Kawasaki, Takatoshi Nakashima
Masanori Gonda, Tatsuya Osuga, Kazunori Hasegawa, Takatoshi Nakashima, Department of Gastroenterology, Takatsuki General Hospital, Takatsuki 5691192, Japan
Yoshihiro Ikura, Department of Pathology, Takatsuki General Hospital, Takatsuki 5691192, Japan
Kentaro Kawasaki, Department of Surgery, Takatsuki General Hospital, Takatsuki 5691192, Japan
Author contributions: Gonda M, Osuga T and Hasegawa K contributed to study concept and design; Gonda M and Osuga T contributed to data collection; Gonda M, Osuga T and Ikura Y contributed to data verification; Osuga T and Ikura Y contributed to data management, interpretation and supervision; Osuga T and Ikura Y contributed to statistical analysis and drafted the manuscript; Kawasaki K and Nakashima T contributed to critical revision of the manuscript.
Institutional review board statement: The institutional review boards in Takatsuki General Hospital (Approval No: 2018-1) approved this study including an opt-out method of informed consent.
Informed consent statement: Patient’s consent was obtained through the opt-out method instead of a written form.
Conflict-of-interest statement: All authors declare no conflicts of interest related to this article.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Tatsuya Osuga, MD, PhD, Chief Physician, Doctor, Postdoc, Department of Gastroenterology, Takatsuki General Hospital, 1-3-13 Kosobe-cho, Takatsuki 5691192, Japan. tatsuya.osuga@ajk.takatsuki-hp.or.jp
Received: December 26, 2019
Peer-review started: December 26, 2019
First decision: February 18, 2020
Revised: March 25, 2020
Accepted: April 1, 2020
Article in press: April 1, 2020
Published online: April 14, 2020
Abstract
BACKGROUND

Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.

AIM

To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.

METHODS

Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.

RESULTS

Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients’ poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.

CONCLUSION

HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients’ prognoses.

Keywords: Hepatic portal venous gas, Surgical treatment, Conservative treatment, Computed tomography, Intestinal necrosis, Prognostic factor

Core tip: Hepatic portal venous gas caused by intestinal necrosis is a life-threatening condition and requires surgery. Computed tomography findings of free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis are useful criteria to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are valuable as predictors of patients’ prognoses.