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Is Pneumatosis and Portal Venous Air an Indication for Surgical Intervention: A Systematic Review

N Pina1, D Winston1, T Kasprzycki1

  • 1TidalHealth Peninsula Regional, Salisbury, MD, USA.

The American Surgeon
|February 5, 2025
PubMed

Insights

Pneumatosis and portal venous gas findings indicate a 31% mortality rate, significantly lower than the previously estimated 70%. Surgical decisions for these radiological signs should consider the patient's overall clinical condition, not solely imaging results.

Area of Science:

  • Radiology
  • Gastroenterology
  • Surgical Critical Care

Background:

  • Pneumatosis and portal venous gas are historically linked to high mortality (70%) and immediate surgery due to suspected acute mesenteric ischemia.
  • Increased use of cross-sectional imaging reveals these findings in patients with less severe symptoms, questioning the traditional high mortality rate.
  • This challenges the established clinical paradigm for managing patients presenting with these specific radiological indicators.

Purpose of the Study:

  • To systematically review and assess the actual mortality rate associated with pneumatosis and portal venous gas detected on initial imaging.
  • To differentiate mortality based on the presence or absence of acute mesenteric ischemia in patients with these radiological findings.
  • To provide evidence-based guidance for surgical intervention decisions in patients with pneumatosis or portal venous gas.

Main Methods:

  • A systematic literature search was conducted across Embase, Web of Science, PubMed, and Scopus databases.
  • Eleven relevant articles were included in the final analysis, encompassing a total of 308 patients for mortality assessment.
  • Data extraction focused on overall mortality, and mortality stratified by the presence or absence of confirmed mesenteric ischemia.

Main Results:

  • The overall mortality rate for patients with pneumatosis or portal venous gas was 31% (22/308), substantially lower than the historical 70% estimate.
  • In patients with confirmed acute mesenteric ischemia, the mortality rate was high at 69% (51/74).
  • Conversely, patients without confirmed ischemia exhibited a significantly lower mortality rate of 14% (22/159).

Conclusions:

  • The overall mortality associated with pneumatosis and portal venous gas is considerably lower than previously believed.
  • Distinguishing between ischemic and non-ischemic causes is crucial, as mortality varies dramatically between these groups.
  • Clinical judgment, considering the patient's overall condition, should guide surgical decisions rather than relying solely on the presence of pneumatosis or portal venous gas.
Keywords:
mortalitypneumatosisreviewvenous gas

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