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Nonoperative Management of Perforated Hollow Viscera in a Palliative Care Unit.

S urgical dogma holds that perforation of a hollow viscus, indicated by pneumoperitoneum on imaging, mandates abdominal explo1,2 ration. Nonsurgical causes of pneumoperitoneum exist, but when perforation is the presumed etiology of free air in the abdomen, operative repair of the perforation has been standard. Successful nonoperative management of perforated viscera occurs, but it is generally reserved for patients with reassuring clinical findings. Occasionally surgeons encounter patients with a perforated viscus whose clinical findings suggest abdominal exploration is necessary, but who have life-threatening illnesses that make operation treacherous and its value questionable. Comfort-focused care for these patients is associated with a 100% 30-day mortality, but little has been written on these patients’ experience. Surgeons have little guidance for counseling patients and families about the outcome of nonoperative management. We present here a case series of 8 patients from our institution with a perforated hollow viscus transferred to our palliative care unit (PCU) for comfort-focused care after a decision not to operate. We included all patients transferred to our PCU from 2012 to 2017 with computed tomography (CT) findings of extraluminal air in the abdomen and a surgical consultation that resulted in a decision not to operate, and we identified 12 such patients. The 2 surgeon coauthors (MCS, OLG) reviewed the details of these patients, and patients were excluded if nonoperative management would likely have been recommended even in the absence of a terminal diagnosis. Four such patients were excluded: 1 with Hinchey class I diverticulitis, 2 with contained iatrogenic perforations, and 1 with contained cecal perforation from Olgilvie syndrome. The authors felt that the remaining 8 patients would likely have been recommended to undergo surgical exploration if not for their life-limiting diagnoses (Table 1). In the PCU, patients generally received broad spectrum intravenous antibiotics while they were alert and able to spend meaningful, awake time with their loved ones. These antibiotics were discontinued when the treating palliative care physician felt they were no longer providing clinical benefit. The palliative care providers communicated regularly with the patient or the patient’s surrogate on daily rounds and as needed when the patient’s condition