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PubMedDate not supplied

Perforated gastric and duodenal ulcers in an urban African population.

BACKGROUND: Perforations of the stomach and duodenum are frequent causes of acute generalized peritonitis in our environment. This is a prospective study of 331 cases of gastric and duodenal perforations. STUDY DESIGN: A consecutive series of adult patients admitted and treated for acute generalized peritonitis due to peptic ulcer perforations was studied prospectively from January 1998 to June 2004. A specially designed proforma was used to record patient characteristics, clinical and operative findings and outcome. Additional information on self-medication and other relevant social habits was obtained and recorded. The data was analysed and the ratio of gastric to duodenal perforations as well as factors associated with perforations determined. RESULTS: More males were affected by a ratio of 3.3:1. For all the patients the median age was 55.0 and the mean age was 52.2 +/- 17.5 years. The mean age of the perforated gastric ulcer patients was 47.7 +/- 17.1 years but higher for perforated duodenal ulcer patients at 64.8 +/- 11.4 years. There were 244 gastric and 87 duodenal perforations giving a ratio of 2.8:1. Most of these perforations were associated with the intake of Non Steroidal Anti Inflammatory Drugs (NSAIDS) 158 (47.7%), habitual ingestion of herbal medicines or concoctions 81 (24.5%) and prolonged fasting for religious reasons, 18 (5.4%). Acute renal failure 32 patients (31.1%), continuing or persistent peritonitis 12 patients (11.6%), wound infection 25 patients (24.3%), and chest infection 12 patients (11.6%), were some of the 103 post-operative complications seen. The overall mortality was 73( 22.1%). The death rate from perforated duodenal ulcer was 27 (32.2%) and that from perforated gastric ulcer was 46 (20.1%). CONCLUSION: In our community perforated gastric ulcer is seen more often than perforated duodenal ulcer. These gastric perforations are related to the widespread use of NSAIDS and herbal medicines.

Adolescent↗
PubMed2004

Surgical approach to neonatal intestinal perforation. An analysis on 85 cases (1991-2001).

AIM: Primary gastrointestinal perforations have an incidence of between 1% and 3% in NICU patients. The 3 Centers participating in this study cover nearly 40% of the NICU population of the Lazio Region--Italy. The aim of this study is to discuss factors affecting survival in patients affected by a primary intestinal perforation. METHODS: From 1991 to 2001, 67 cases of 85 with a neonatal gastrointestinal perforation, were related to primary bowel lesions. Necrotizing enterocolitis (NEC) was not always the cause of perforation and in many patients an isolated bowel lesion without signs of NEC was found. The aim of this study was to examine clinical and intraoperative findings of NEC and non NEC perforations and their impact on survival. A relevant number of these patients were extremely low-birth weight (ELBW). Controversies about treatment of this category of neonates are discussed. RESULTS: Patients were 37 males and 30 females (mean birth weight 1 274.8 g, mean gestational age 28.9 weeks, mean age at perforation 10 days). Overall survival was 56.8%. Patients were divided by intraoperative findings in 2 groups: NEC (n=48), or isolated intestinal perforation (IIP) without signs of NEC (n=19). Differences between these 2 groups with regard to birth weight, maturity, associated cardiac anomalies (patent ductus arteriosus, PDA) were significant. NEC and IIP behaved as 2 distinct entities, each with peculiar clinical (age at perforation, oral feeding, need of ventilatory support) and radiological aspects. At surgery, multiple lesion on necrotic bowel were typical of NEC versus single, isolated perforations on healthy bowel typical of IIP. Overall survival was almost identical in the 2 groups (59% vs 58%). ELBW patients (55% of the total neonatal intestinal perforations) were also studied. There were 21 patients with NEC and 16 with IIP. The 2 groups were different in age at perforation, previous oral feeding and associated cardiac anomalies (PDA). Overall survival was 62% for NEC and 50% for IIP. A laparotomy was always performed. Temporary peritoneal drainage was done in 4 cases only. Results were better when intestinal diversion was performed rather than resection and primary anastomosis. Almost all NEC patients had multiple perforations and extended bowel necrosis. CONCLUSION: NEC is the most frequent cause of neonatal intestinal perforation. This is a quite distinct entity from IIP, which must always be differentiated preoperatively and which is most frequently found among low birth weight newborns. As far as surgical treatment of perforation among ELBW neonates is concerned, peritoneal drainage might be reasonably performed when a single lesion on healthy bowel as in IIP is clearly diagnosed but it could be inadequate for NEC patients.

Digestive System Surgical Procedures↗
PubMed2004

[Spontaneous healing of various types of rat tympanic membrane perforation].

OBJECTIVE: To investigate the spontaneous healing process of various types of rat tympanic membrane perforation, study the perforation healing mechanism. METHODS: Fifty rats were divided into five groups in randomization, and performed perforations phi = 2.5 mm, 1 mm, respectively in the center of tympanic membrane pars tensa, posterior marginal perforation (phi = 1.5 mm) in pars tensa, the handle of malleus cauterized with chromic acid after tympanic membrane 3/4 excision, and perforation (phi = 1.5 mm) in the center of pars flaccid, The histology of the perforations healing process was observed with light microscope. RESULTS: The epithelia retracted in the early stage after perforation. The epithelia near the annulus and manubrium showed hyperplasia. The epithelia hyperplasia also appeared the intact annulus region remote to the perforation. The middle connective tissue layer reacted later than the epithelial layer. The defects were closed first by the accumulation of the epithelial cells. The difference of healing time had no statistics significance between the big and small perforations. One ear perforated, but the other side intact ear appears no change. The epithelia didn't migrate into the tympanic cavity in the posterior marginal perforations. All the perforations healed after the manubriums of the malleus were damaged. Perforations in pars flaccid healed more quickly. CONCLUSIONS: The normal migration of the epithelia of the tympanic membrane played an important role in the healing of perforation. The generation center was located near tympanic annulus and manubrium of the malleus, so the protection of these two regions was very important in the middle-ear surgery.

Animals↗
PubMed1998

Bone and temporal fascia graft for the closure of septal perforation.

OBJECTIVES: To assess the reliability of temporal fascia and bone graft for the closure of septal perforation. STUDY DESIGN: Prospective longitudinal non-randomized. METHODS: The repair of septal perforation was performed using endonasal dissection; suture of the borders of the perforation on at least one side, and interposition of a graft of temporal fascia with bone, either a perpendicular plate of ethmoid (six) if available or mastoid cortex (three) if not. RESULTS: All patients had closure without re-perforation. Eight out of nine patients had complete closure of the perforation (88.8 per cent). These patients had perforations of less than 3 cm in diameter. The ninth patient had a perforation of more than 3 cm diameter (3.5 x 2.5 cm), and obtained a closure of about 80 per cent of the original perforation. The remaining perforation was in the posterior part of the nose. The patient was relieved of his symptoms (crusting and bleeding). This incomplete closure was most probably due to migration of the graft immediately after surgery. There was no morbidity of the donor site or the ear in the mastoid cortex graft group of patients. This is to our knowledge the first report of the use of the mastoid cortex as a graft in septal perforation. CONCLUSIONS: We consider that the graft of temporal fascia with bone is very reliable, and the use of bone ensures closure while avoiding the complications of a lax septum in large perforations. The technique is suitable for perforations up to 2.5 cm diameter. Perforations larger than 3 cm in diameter are more difficult to close, but closure of the anterior part of the perforation will relieve the patient from the most annoying symptoms.

Ethmoid Bone↗
PubMed2000

The value of preoperative Doppler sonography for planning free perforator flaps.

The individual perforating vessels have a high degree of anatomical variation, therefore it is desirable to conduct a careful examination of them before undertaking a perforator flap operation. Because locating the vessels beforehand makes performing the operative procedure much easier, the aim of the present study was to assess the value of using simple acoustic Doppler sonography to plan a perforator flap operation. The vessel examinations were carried out before taking 46 free microvascular flaps from either the lower abdominal wall or the buttock for reconstructive breast surgery. The perforating vessels located were marked, and their position relative to the umbilicus or the most cranial point of the rima ani recorded using a coordinate system. In 40 patients, a perforator flap operation (deep inferior epigastric perforator flap, n = 32; superior gluteal artery perforator flap, n = 8) was actually carried out; in six of these patients, a myocutaneous flap was used because of the insufficient availability of perforating vessels. Before the operation, perforating vessels were marked for each patient, with an average of 7.3 for the deep inferior epigastric perforator flap and 6.5 for the superior gluteal artery perforator flap. Out of 286 vessels marked for later perforator flaps, 162 were identified during the operation. A preoperatively marked vessel was used in 37 of 40 patients. In the remaining patients, a vessel was used that had not been previously marked. The vertical and horizontal distance between the perforating vessels identified during the operation and the preoperative marks averaged 0.8 cm. The results show preoperative Doppler sonography to be useful for locating the position of individual perforating vessels, making it much easier to find them during the operation.

Adult↗
PubMed2002

Early and late clinical outcomes following coronary perforation in patients undergoing percutaneous coronary intervention.

Coronary perforation is a rare but serious complication that occurs during percutaneous coronary intervention (PCI). This study examines the frequency of coronary perforation during PCI, evaluates the management strategies used to treat perforations, and describes the long-term prognosis of patients who have developed coronary perforation during PCI. Coronary perforations were found in 69 (0.93%) of 7,443 consecutive PCI procedures, occurring more often after use of a new device (0.86%) than after use of balloon angioplasty (0.41%) (p<0.05). Coronary perforation was attributable solely to the coronary guidewire in 27 (0.36%) cases. Coronary perforations were divided into 2 types: (1) Those with epicardial staining without ajet of contrast extravasation (type I, n=51), and (2) those with a jet of contrast extravasation (type II, n= 18). Patients with type I and type II perforations were managed by observation only (35% and 0%, respectively), reversal of anticoagulation (57% and 94%), pericardiocentesis and drainage (27% and 61%), and prolonged perfusion balloon angioplasty (16% and 100%). Two patients with type II perforations required emergency coronary artery bypass surgery. There were no in-hospital deaths. Late pseudoaneurysms developed in 18 (28.6%) patients during the 13.4 +/- 11.3 months' follow-up period, and were more common in patients with type II perforations (72.2% vs 11.1% with type I perforations; p<0.001). During the follow-up period, no patient had evidence of coronary rupture. The results suggest that coronary perforation is uncommon after PCI, and can be managed without cardiac surgery in the majority of cases. Late pseudoaneurysms developed in some patients, particularly in patients with type II perforations, but there were no late consequences of coronary perforation after PCI.

Angioplasty, Balloon, Coronary↗
PubMed1992

Occult glove perforations: frequency during interventional radiologic procedures.

Because the intact surgical glove is an important barrier against exposure to blood and other body fluids, occult glove perforations occurring during procedures may have implications for infection control and protection of health care workers. Although the frequency of occult glove perforations during surgery has been studied, no such data have been reported for interventional radiology. This study was designed to determine the frequency of occult glove perforations in interventional radiology. Gloves used during interventional radiologic procedures were collected and tested for occult perforations according to previously accepted methods. The frequency of occult defects in unused gloves was also determined. A form completed for each pair of gloves indicated length of use, awareness of perforations, and information about the procedure. The anatomic distribution of perforations was also studied. Occult perforations were found in 49 (10%) of 492 used gloves. The frequency of defects in unused gloves was 1% (2/160). Gloves worn fewer than 2 hr had a perforation rate of 7% (29/406), and those worn 2 hr or longer had a rate of 23% (20/86; p less than .0001). Perforations were noticed by the wearer in only three (6%) of the 49 perforations. The perforation rate for inner gloves of a double-glove set was 3% (1/34; the corresponding outer glove also was perforated). Although the 10% rate of occult glove perforation during interventional radiologic procedures found in this series is lower than rates described with surgical procedures, it is not insignificant. The significant increase in the rate of perforation when gloves are worn more than 2 hr suggests that gloves should routinely be changed at or before 2 hr of wear, particularly in procedures involving high-risk patients.

Equipment Failure↗
PubMed2002

ERCP-related perforations: risk factors and management.

BACKGROUND AND STUDY AIMS: Perforations during endoscopic retrograde cholangiopancreatography (ERCP) are rare, and the management of these perforations is variable, with some patients requiring immediate surgery and others only conservative management. We reviewed all ERCP-related perforations at our institution to determine: a) their incidence; b) clinical outcomes; c) which management approaches gave the best results; and d) which factors predict a perforation. PATIENTS AND METHODS: All patients who underwent ERCP and suffered perforation were reviewed. To compare the length of hospital stay of the perforation group with that of patients suffering a different complication, patients who developed post-ERCP pancreatitis were also reviewed. To evaluate predictors of ERCP-related perforations, three groups were compared: group 1 (n = 49), normal ERCP/no complications; group 2 (n = 52), ERCP complicated by pancreatitis; and group 3 (n = 33), ERCP with perforation. RESULTS: Of 33 patients with confirmed ERCP-related perforations, only seven patients required surgical intervention. The overall length of hospital stay (6.5 +/- 3.5 days) was significantly longer (P = 0.003) than that of a random group of patients with the complication of post-ERCP pancreatitis (4.7 +/- 2.6 days). According to univariate analysis, risk factors included: sphincterotomy (odds ratio [OR] 9.0, 95 % confidence interval [CI] 3.2 - 28.1); sphincter of Oddi dysfunction (OR 3.8, 95 % CI 1.4 - 11.0); and dilated common bile duct (OR 4.07, 95 % CI 1.63 - 10.18, P = 0.003). In the multivariate logistic regression analysis, additional predictive factors included the duration of procedure (OR 1.021, 95 % CI 1.006 - 1.036), and biliary stricture dilation (OR 7.2, 95 % CI 1.84 - 28.11). CONCLUSIONS: (i) The incidence of ERCP-related perforations is very low (0.35 %). (ii) Esophageal, gastric and duodenal perforations usually require surgery, but sphincterotomy- and guide wire-related perforations rarely do so. (iii) Factors which carry increased risk of an ERCP-related perforation include suspected sphincter of Oddi dysfunction, greater age, a dilated bile duct, sphincterotomy, and longer duration of the procedure.

Adult↗
PubMed1998

Outcome of large-bowel perforation in patients with colorectal cancer.

PURPOSE: Perforation of the colon is seldom associated with malignant disease. Operative mortality varies widely in published studies and little is known about patterns of failure and long-term outcome. An observational study was undertaken to assess the outcome of colorectal cancer complicated by perforation. METHOD: We reviewed a series of 83 consecutive patients treated during a 14-year period at one institution. RESULTS: Fifty-four (65 percent) patients had perforation of the tumor itself, and 29 (35 percent) had diastatic perforation proximal to an obstructing tumor. Twenty-six (31.5 percent) patients had metastatic disease at laparotomy. Primary resection of the diseased segment was performed in 47 (87 percent) patients with perforation of the tumor itself and in 21 (72.4 percent) patients with diastatic perforation proximal to an obstructing tumor. However, only 57 patients (39 (72.2 percent) with perforation of the tumor itself; 18 (62 percent) with diastatic perforation proximal to an obstructing tumor; P = not significant) were potentially cured. Operative mortality was 16.7 and 48.3 percent, respectively (P < 0.01) and correlated significantly with Hinchey's stage (P < 0.001) and advanced disease (P = 0.023). At a mean follow-up of 43 (median 31) months, 21 (46 percent) of the 46 potentially cured survivors were alive. The local recurrence rate was 22.9 percent in patients with perforation of the tumor itself and 18.2 percent in patients with diastatic perforation proximal to an obstructing tumor (P = not significant). Peritoneal seeding occurred in 17 and 0 percent (P = not significant); the mean disease-free interval was 33.9 and 49.9 months (P = not significant); and five-year cumulative disease-related survival probability was 0.51 and 0.90 (P = 0.049), respectively. CONCLUSIONS: Diastatic perforation proximal to an obstructing tumor is associated with higher operative mortality and better cancer-related survival than a tumor perforating through the bowel wall. Early diagnosis in diastatic perforation and aggressive management of sepsis associated with radical surgical resection is recommended.

Aged↗
PubMed1999

Surgery may be curative for patients with a localized perforation of rectal carcinoma.

BACKGROUND: Perforation at the time of operation adversely affects the prognosis of rectal cancer. These procedures have been termed 'palliative' or 'non-curative'. The long-term outcome of generalized perforations may be different from that of localized or contained perforations. Although the oncological results may be compromised when the tumour is perforated, results in cases where the perforation is contained may not be as bad as previously thought. An attempt was made to examine the intermediate and long-term results for locally contained perforated rectal cancers. METHODS: Some 848 patients with rectal cancer were operated on between March 1989 and December 1995. Of these, 42 (5 per cent) had a locally contained perforation of the rectum. Median follow-up was 23 (range 12-74) months. RESULTS: The survival of patients with locally contained tumour perforation who underwent resection without macroscopic residual disease (40 per cent at 5 years) was significantly better than that of patients with metastatic disease at the time of surgery (zero at 4 years) (P < 0.01). The survival of patients in whom the tumour was inadvertently perforated during operation was similar to that of patients with locally contained spontaneous tumour perforations. The incidence of local recurrence in these perforated cases was low provided that a wide tumour clearance was achievable at the time of operation. Operative mortality and morbidity rates were not significantly different but the incidence of postoperative wound infection was marginally higher among patients with perforation. CONCLUSION: If clear margins can be obtained at the time of operation the prognosis of locally contained perforated rectal cancers is good and approaches that of a potentially curative resection.

Adult↗
PubMed2000

Peritoneal drainage as definitive treatment for neonates with isolated intestinal perforation.

BACKGROUND/PURPOSE: To better define the indications for peritoneal drainage (PD) in premature babies with intestinal perforation, the authors reviewed their experience with this procedure in a tertiary neonatal intensive care setting. METHODS: The charts of all neonates who underwent PD as initial treatment for intestinal perforation between 1996 and 1999 were reviewed. Those patients with pneumatosis intestinalis on abdominal radiograph had perforated necrotizing enterocolitis (NEC) diagnosed; whereas, those infants with no pneumatosis had isolated intestinal perforation diagnosed. The clinical characteristics and outcomes of these 2 groups were compared. RESULTS: Twenty-one premature neonates had primary PD between 1996 and 1999, 10 for isolated intestinal perforation and 11 for perforated NEC. Patients with isolated intestinal perforation had lower birth weights (708 v 949 g; P < .05), were less likely to have started feedings (30% v 91%, P < .05), and the perforation developed at an earlier age (10.6 v 28.0 d, P < .05) compared with the patients who had perforated NEC. Only 2 of 10 infants with isolated perforation required subsequent laparotomy (at 10 weeks for stricture and 12 weeks for a persistent fistula). For these patients, the long-term survival rate was 90%. In contrast, 8 of 11 infants with perforated NEC required laparotomy, and although the 30-day survival rate was 64%, the long-term survival rate was only 27%. CONCLUSIONS: Peritoneal drainage provides successful and definitive treatment for most premature babies with isolated intestinal perforation. For neonates with perforation caused by NEC, peritoneal drainage may provide temporary stabilization, but most of these infants require subsequent laparotomy, and few survive.

Drainage↗
PubMed2006

Determinants of hearing loss in perforations of the tympanic membrane.

BACKGROUND: Although tympanic membrane perforations are common, there have been few systematic studies of the structural features determining the magnitude of the resulting conductive hearing loss. Our recent experimental and modeling studies predicted that the conductive hearing loss will increase with increasing perforation size, be independent of perforation location (contrary to popular otologic belief), and increase with decreasing size of the middle-ear and mastoid air space (an idea new to otology). OBJECTIVE: To test our predictions regarding determinants of conductive hearing loss in tympanic membrane perforations against clinical data gathered from patients. STUDY DESIGN: Prospective clinical study. SETTING: Tertiary referral center. INCLUSION CRITERIA: Patients with tympanic membrane perforations without other middle-ear disease. MAIN OUTCOME MEASURES: Size and location of perforation; air-bone gap at 250, 500, 1,000, 2,000, and 4,000 Hz; and tympanometric estimate of volume of the middle-ear air spaces. RESULTS: Isolated tympanic membrane perforations in 62 ears from 56 patients met inclusion criteria. Air-bone gaps were largest at the lower frequencies and decreased as frequency increased. Air-bone gaps increased with perforation size at each frequency. Ears with small middle-ear volumes, < or = 4.3 ml (n = 23), had significantly larger air-bone gaps than ears with large middle-ear volumes, > 4.3 ml (n = 39), except at 2,000 Hz. The mean air-bone gaps in ears with small volumes were 10 to 20 dB larger than in ears with large volumes. Perforations in anterior versus posterior quadrants showed no significant differences in air-bone gaps at any frequency, although anterior perforations had, on average, air-bone gaps that were smaller by 1 to 8 dB at lower frequencies. CONCLUSION: The conductive hearing loss resulting from a tympanic membrane perforation is frequency-dependent, with the largest losses occurring at the lowest sound frequencies; increases as size of the perforation increases; varies inversely with volume of the middle-ear and mastoid air space (losses are larger in ears with small volumes); and does not vary appreciably with location of the perforation. Effects of location, if any, are small.

Acoustic Impedance Tests↗
PubMedDate not supplied

Perforated peptic ulcer in Hong Kong and New South Wales.

Direct comparisons of ulcer perforation rates and trends between countries have not been made in the past. Data on hospital admissions for perforated peptic ulcer during 1 January 1979 to 31 December 1985 were collected in Hong Kong (5868 perforations) and New South Wales, Australia (1669 perforations). Age and sex specific rates per 100,000 population were calculated. In Hong Kong, annual duodenal ulcer and gastric ulcer perforation rates were 13-16 and under two per 100,000 population respectively. In New South Wales, the corresponding rates were between three and four and under two per 100,000 population, respectively. The male:female ratios for duodenal ulcer perforation were consistently about 5:1 in Hong Kong and 2:1 in New South Wales, and for gastric ulcer perforation about 2:1 and 1:1, respectively. The incidence of perforation increased with age, and there was a statistically significant rise, over time, in duodenal but not gastric ulcer perforation rates in persons aged over 60 years in New South Wales; similar trends were seen in Hong Kong. Thus duodenal ulcer perforation occurs five times more commonly in Hong Kong than in New South Wales and this is largely accountable for by the higher rates of duodenal ulcer perforation in Chinese than in Australian males. Such geographical differences can best be explained by the occurrence of multiple aetiological mechanisms in ulcer perforation. Furthermore, there appears to be an increased susceptibility and an appreciable rising trend for duodenal ulcer perforation to occur in the elderly.

Adult↗
PubMed1992

[Acute abdomen with intraperitoneal bowel perforation-demonstration by CT scan].

Ninety-eight cases of surgically proved bowel perforation in VGH-Kaohsiung within one year were reviewed. Among them, 25 patients received abdominal CT scans before operation. Free gas or fluid could be demonstrated with CT scan in 80% of cases though sometimes the fluid was too scanty to be well recognized. Local abscess formation with or without tumor mass lesion (n = 3), local fluid accumulation (n = 1) and negative CT findings (n = 1) constituted the remaining 20% of cases. The recognition of perforation sites depended on direct evidences of perforation such as ulceration, abscess formation and tumor mass lesion (32%), or indirect evidences including hematoma formation, dependent extraluminal gas accumulation and phlegmonous reaction (12%). An inexplicable localized extraluminal fluid accumulation might also suggest a possibility of hollow organ perforation and lead to the recognition of perforation site in the absence of free gas (4%). Absence of extraluminal fluid or gas can not completely rule out the possibility of hollow organ perforation (4%). Massive free air, especially with an air-fluid level, suggested a possibility of upper abdominal perforation. The perforation hole located at the anterior wall of stomach produced more free gas than that located at posterior wall. Air-fluid levels could never be identified in the cases of lower gastrointestinal perforations. Local bowel wall thickening and the distribution of free gas contributed little to the recognition of perforation site. Extravasation of oral contrast media sometimes led to the diagnosis of gastrointestinal perforation but was not necessary to be noted around the perforation hole and did little contribution to the perforation site recognition.(ABSTRACT TRUNCATED AT 250 WORDS)

Abdomen, Acute↗
PubMed1985

Differences in pathogenesis, incidence and outcome of perforation in inflammatory bowel disease.

We have studied the patient records of 49 or 1,623 patients in whom perforation occurred during the course of inflammatory intestinal disease. Perforation occurred most commonly with toxic megacolon in UC, but without toxic megacolon in Crohn's disease of the colon. The incidence of perforation was significantly greater in UC than in Crohn's disease involving the colon. This was due primarily to the higher incidence of perforations with toxic megacolon in the former. The incidence of toxic megacolon was significantly greater in ulcerative colitis than in Crohn's disease involving the colon (CC and IC) and in UC than in ileocolitis. Although almost twice as frequent in UC than in Crohn's colitis alone, a significant difference could not be demonstrated in this series for patients with UC compared with CC. In UC, the incidence of perforation was 28 times as frequent if toxic colonic dilation occurred, compared with ten times the frequency of TCD in Crohn's disease involving the colon. There was a significantly higher incidence of perforation in patients with UC with toxic megacolon. The incidence of colonic perforation in the absence of toxic megacolon was similar in the two series (7 of 552 for UC, 1.2 per cent, versus 11 of 607 for CDC, 1.8 per cent). Mortality was no different in toxic megacolon in patients with UC compared with those with Crohn's disease or in patients with UC with free perforation compared with those with sealed perforation. Mortality was significantly greater in patients with perforation in UC than in those with Crohn's disease in the absence of toxic megacolon. All 15 patients with spontaneous free perforation in Crohn's disease treated by resection or exteriorization with diversion survived compared with four of seven deaths of free perforation in UC. We have no explanation for the remarkable difference in survival of free perforation in the absence of toxic megacolon in UC and CD, but it may be due to differing immunologic states or pathogenetic mechanisms.

Colitis↗
PubMed1987

A serial-section study of perforated synapses in rat neocortex.

The morphology of perforated synapses in the molecular layer of rat parietal cortex has been studied in 28-day-old animals. Of the perforated synapses analyzed, 92% were axospinous and of these all had asymmetrical contacts. A spinule was present in 20% of them, and 63% had a negative curvature (concave with respect to the presynaptic terminal) overall. Up to 95% of perforated synapses had one or more negatively-curved segments. The perforated synapses studied were characterized by postsynaptic densities (PSD) with a mean length of 581 nm, compared with 233 nm for non-perforated synapses. A study of over 100 serially sectioned synapses demonstrated that, in perforated synapses, the PSD and perforations often had a highly irregular shape and arrangement, the site of the perforation frequently projected into the presynaptic terminal, and coated evaginations of membrane, or coated vesicles, were sometimes found at the site of a perforation or towards the periphery of perforated PSDs. Preliminary reconstructions of perforated synapses suggest that, for descriptive purposes, three types can be recognized. Criteria are formulated for determining, on the basis of a study of single sections, which non-perforated profiles belong to perforated synapses.

Animals↗
PubMed1994

Coronary perforation after excimer laser coronary angioplasty: the Excimer Laser Coronary Angioplasty Registry experience.

OBJECTIVES: This study assessed the frequency of perforation with excimer coronary angioplasty. BACKGROUND: Coronary artery perforation after conventional percutaneous transluminal coronary angioplasty is extremely rare. Because laser coronary angioplasty involves actual tissue ablation, it has an increased potential for perforation. METHODS: All patients in the Excimer Laser Coronary Angioplasty Registry were included in this prospective study. Those who had a perforation related to the procedure were compared with those who did not have this complication. RESULTS: Of 2,759 consecutive patients in the Excimer Laser Coronary Angioplasty Registry, 36 (1.3%) had perforation. In these patients, the left anterior descending coronary artery was the most frequently treated vessel (53%). There were no differences in fiber sizes between patients with and those without perforation. Among the patients with perforation, 36.1% required coronary artery bypass surgery, 16.7% experienced an infarction and 5.6% had a fatal outcome. Among the patients without perforation, the rates were 3.1%, 3.8% and 0.6%, respectively. However, 41.7% of the patients with documented coronary artery perforation did not need coronary artery bypass surgery or experience myocardial infarction or death. No angiographic characteristics distinguished lesions with from those without perforation. The frequency of coronary artery perforation declined over time with increasing operator experience, from 1.6% in the first 1,888 patients to only 0.4% in the last 1,000 patients (p = 0.002). CONCLUSIONS: With increasing operator experience, the rate of perforation with excimer laser coronary angioplasty has decreased. When perforation occurs, subsequent event rates increase.

Angioplasty, Balloon, Coronary↗
PubMed2005

A prospective study of the fate of venous leg perforators after varicose vein surgery.

OBJECTIVE: To describe the fate of perforator veins after surgical treatment of varicose veins and factors that influence this. METHODS: This prospective study of 104 patients assessed perforator veins by using duplex ultrasound scanning in 145 limbs before superficial vein surgery for varicose veins. Veins were marked preoperatively with ultrasound guidance and ligated with an open procedure; those missed were later treated with sclerotherapy. Duplex ultrasound scans and air plethysmography were used to confirm surgical success within 1 month and to monitor recurrence at 6 months, 1 year, and 3 years. RESULTS: A total of 850 incompetent perforators were treated, but 5.7% were missed and required further ablation. After 3 years, 75.8% of the limbs had developed further incompetent perforators for a total of 380 incompetent perforators. The number of ultrasound-detectable competent perforators had also increased from 356 to 1047 in that time. The incompetent perforators arose by (1) new vessel formation at the site of previous ligation in 152 (40.4%), (2) changes in pre-existing perforator vessels at other sites in 225 (59.2%), and (3) vessels missed at treatment (< 1%). The diameter of the neovascular channels (3.0 +/- 1.0 mm) was greater than the other incompetent perforators (2.7 +/- 1.0 mm; P < .001). The anatomic distribution of the neovascular recurrences was also different, with 63% found in the paratibial region. The number of new incompetent perforators in a limb was associated with the clinical and physiologic severity of venous disease before surgery, but not to body mass index, gender, or age (P < .01). CONCLUSION: This study shows that incompetent perforator recurrence after surgery is far more common than previously recognized and is primarily due to either neovascularization of previously ligated perforators or the development of incompetence in newly detected perforators in association with persistent venous disease rather than due to poor surgery.

Adult↗