Published online Apr 14, 2020. doi: 10.3748/wjg.v26.i14.1628
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
Hepatic portal venous gas (HPVG) is generally recognized as a life-threatening sign in patients with serious intestinal damage. While most of such patients require surgical treatments, some patients can recover without surgery.
We aimed to establish an optimal treatment strategy for HPVG, i.e., how to select surgical or conservative treatments.
We tested accuracy of our original computed tomography (CT)-based selection criteria. Additionally, we found if there were reliable prognostic factors in non-surgical cases.
Thirty-four cases of HPVG were included. Surgical indication had been decided by CT findings, including free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis. Their clinical findings and treatment outcomes were analyzed separately in the surgical cases and non-surgical cases.
Of eight surgical cases, seven patients (87.5%) survived but one (12.5%) died. All the surgical patients had severe intestinal damage and the necrotic portions were resected. In addition to 14 cases without surgical indication, 12 inoperable cases were defined as non-surgical cases (total 26 cases). Three (25%) of the 12 inoperable patients survived. Only one patient (7%) died among the 14 patients diagnosed as being surgery unnecessary. 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.
Our CT-based criteria were useful to determine the surgical indication for HPVG patients. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients’ prognoses.
Our two-step decision and prediction process may be applicable not only for selection of surgical cases but also for considering non-surgical but intensive treatments for such inoperable patients.