Pneumoperitoneum in the cancer patient

Background: Cancer patients may be at increased risk for pneumoperitoneum due to local tumor invasion, immunosuppression, chemotherapy, and frequent endoscopy. The purpose of this study was to characterize clinical presentations and management strategy for pneumoperitoneum in cancer patients. Methods: All patients with an ICD-9 diagnosis of visceral perforation or who had undergone a surgical oncology consultation between January 2000 and October 2006 were identified. Those patients with evidence of pneumoperitoneum on radiography underwent chart review. Patients were grouped according to treatment with or without surgery and results were compared using Chi-square and Kaplan Meier analysis. Results: Of 1,750 patients identified, 123 had 124 episodes of pneumoperitoneum. Treatment given was comfort care (n = 19), non-operative management (n = 33), or surgery (n = 72). Disease stage was IV in 89% of the comfort care group, 70% of the non-operative group, and 65% of the surgery group (P = 0.6). Factors predictive of management on univariate analysis were the presence of symptoms at presentation, abdominal tenderness, fever, pneumatosis on imaging, and prior abdominal radiation; but only fever, abdominal tenderness, and abdominal radiation were significant in multivariate analysis. With comfort care, non-operative management, and surgery, 30-day mortality rates were 100%, 12%, and 15%, respectively. Conclusions: Pneumoperitoneum in cancer patients requires a tailored approach that considers both clinical presentation and oncological prognosis. Conventional wisdom for surgical evaluation-symptom severity, pain, and tenderness-still applies, but some patients can be successfully treated without surgery.