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PubMed1995

Myringoplasty for subtotal perforation.

It is often reported that the repair of subtotal perforations is less successful than that of smaller perforations, mainly because it is technically more difficult. The author's surgical technique for subtotal perforations is presented and the results compared with that of myringoplasty for smaller perforations. The study shows that subtotal perforations are associated with a higher incidence of abnormal middle ear mucosa (chi 2 = 11.75, d.f. = 2) and damage to the malleus (chi 2 = 5.60, d.f. = 1) than smaller perforations. However, the success rate of subtotal perforation closure (92.5%) is as good as the closure rate for smaller perforations (94.1%). It is concluded that the size of the perforation is not a major factor in determining whether the graft will be successful in myringoplasty.

Ear Ossicles↗
PubMed2004

Esophageal perforation: the importance of early diagnosis and primary repair.

Esophageal perforation is associated with high morbidity and mortality rates, particularly if not diagnosed and treated promptly. Despite the many advances in thoracic surgery, the management of patients with esophageal perforation remains controversial. We performed a retrospective clinical review of 36 patients, 15 women (41.7%) and 21 men (58.3%), treated at our hospital for esophageal perforation between 1989 and 2002. The mean age was 54.3 years (range 7-76 years). Iatrogenic causes were found in 63.9% of perforations, foreign body perforation in 16.7%, traumatic perforation in 13.9% and spontaneous rupture in 5.5%. Perforation occurred in the cervical esophagus in 12 cases, thoracic esophagus in 13 and abdominal esophagus in 11. Pain was the most common presenting symptom, occurring in 24 patients (66.7%). Dyspnea was noted in 14 patients (38.9%), fever in 12 (33.3%) and subcutaneous emphysema in 25 (69.4%). Management of esophageal perforation included primary closure in 19 (52.8%), resection in seven (19.4%) and non-surgical therapy in 10 (27.8%). The 30-day mortality was found to be 13.9%, and mean hospital stay was 24.4 days. In the surgically treated group the mortality rate was three of 26 patients (11.5%), and two of 10 patients (20%) in the conservatively managed group. Survival was significantly influenced by a delay of more than 24 h in the initiation of treatment. Primary closure within 24 h resulted in the most favorable outcome. Esophageal perforation is a life threatening condition, and any delay in diagnosis and therapy remains a major contributor to the attendant mortality.

Adolescent↗
PubMed2000

Endoscopic perforation of the colon: lessons from a 10-year study.

OBJECTIVES: To assess the incidence, clinical features, and management of endoscopic colon perforations in a large number of patients at a major medical teaching center. METHODS: A retrospective review of medical records of all patients with colon perforations from endoscopy over a 10-yr period. RESULTS: A total of 10,486 colonoscopies were performed over a 10-yr period. There were 20 (0.19%) perforations and two (0.019%) deaths related to colonoscopy and two perforations with no deaths in 49,501 sigmoidoscopies (0.004%). The majority of perforations (65%) occurred in the sigmoid colon. The mean age of the patients was 72 yr (range, 48-87 yr). Multivariate analysis using gender and age showed that female gender was an independent predictor of a higher risk of perforation (p < 0.05). Electrocautery injury (36%) and mechanical injury (32%) from the tip and shaft of the endoscope were the major causes for perforation. Most patients (91%) presented within 48 h of endoscopy. Nine patients (47%) required a surgical resection with primary anastomosis; seven (37%) required a simple closure. The average hospital length of stay was 7.7 +/- 2.8 days. Although trainee endoscopists were involved in only 20% of the colonoscopies performed, eight (40%) perforations occurred while the training fellow was involved in the case. However, this increased risk of perforation with a training fellow was not statistically significant (p = 0.625). CONCLUSIONS: Colonoscopy can result in significant morbidity and carries a small risk of death. Sigmoidoscopy has lower risk. The following situations may represent increased risk to colonoscopy patients: unusual difficulty in traversing the sigmoid colon; difficult examinations in female patients, and difficult examinations performed by trainee physicians.

Aged↗
PubMed1994

Indications for operation in suspected appendicitis and incidence of perforation.

OBJECTIVE: To clarify poorly understood epidemiological features of appendicitis. DESIGN: Retrospective study of consecutive cases from a defined population and analysis of data from published studies. SETTING: County of Jönköping, Sweden. 3029 patients who underwent operation in 1984-9 and 4717 patients from the county town who underwent operation in 1970-89, all for suspected appendicitis, plus 48,426 cases from six reported studies. MAIN OUTCOME MEASURES: Incidences specific for age and sex and temporal trends of perforating and non-perforating appendicitis and removal of a normal appendix. Associations between diagnostic accuracy, rate of perforation, and incidences of removal of a normal appendix and of perforating and non-perforating appendicitis. RESULTS: The incidence of appendicitis was 116/100,000 inhabitants. Appendicitis was more common in male patients. The incidence of perforating appendicitis was independent of age, stable over time, and uninfluenced by the rate of laparotomy, whereas the incidence of non-perforating appendicitis was age dependent, decreasing over time, and related to the diagnostic accuracy and rate of removal of a normal appendix. CONCLUSIONS: Perforating and non-perforating appendicitis seem to be separate entities, and appendicitis that resolves spontaneously is common. This may have important implications for managing suspected appendicitis.

Adolescent↗
PubMed2006

Perforated versus nonperforated acute appendicitis: accuracy of multidetector CT detection.

PURPOSE: To retrospectively evaluate the accuracy of multidetector computed tomography (CT) in the diagnosis of perforated acute appendicitis by using surgery and pathologic examination combined as the reference standard. MATERIALS AND METHODS: The study was institutional review board approved and HIPAA compliant. Informed patient consent was waived. The authors retrospectively identified 244 patients (150 male, 94 female; mean age, 32.8 years; age range, 4-83 years) with pathologically proved acute appendicitis who underwent abdominopelvic multidetector CT. Two radiologists reviewed in consensus the multidetector CT images obtained in all patients for various findings that may be associated with appendiceal perforation. For continuous variables, a comparison of means between the perforated and nonperforated groups was performed by using the Wilcoxon rank sum test. For categorical variables, the sensitivity and specificity of each CT finding for the diagnosis of perforated appendicitis were determined. RESULTS: The CT findings of abscess (99%), extraluminal gas (98%), and ileus (93%) had the highest specificities for appendiceal perforation; however, the sensitivities of these findings were low: 34%, 35%, and 53%, respectively. The appendix was larger in patients with perforated appendicitis: The mean diameter was 15.1 mm compared with a mean diameter of 11.7 mm in patients with nonperforated appendicitis (P < .001). Appendicolith, free fluid, enlarged abdominal lymph nodes, and enhancement defect in the appendiceal wall were neither highly sensitive nor highly specific for the detection of perforation. CONCLUSION: Although certain multidetector CT findings are very specific for the diagnosis of perforated appendicitis, overall multidetector CT sensitivity is poor. Unless abscess or extraluminal gas is present, multidetector CT cannot enable the diagnosis of perforation.

Acute Disease↗
PubMed1992

Acute appendicitis in children: value of sonography in detecting perforation.

OBJECTIVE: We determined the sonographic features of perforating appendicitis in children in order to determine the best criteria for establishing the diagnosis. MATERIALS AND METHODS: Sonograms of the right lower quadrants of 71 children with proved appendicitis were reviewed to determine the value of sonography in distinguishing between nonperforating and perforating appendicitis. The sonographic signs evaluated included the presence or absence of an appendix, an echogenic submucosal layer, increased periappendiceal echogenicity, free or loculated periappendiceal or pelvic fluid collections, and appendicoliths. The sonographic findings were correlated with the surgical and pathologic findings. RESULTS: Forty-five patients had nonperforating appendicitis, and 26 had perforating appendicitis. A sonographically visible appendix was present in all patients with nonperforating appendicitis and in 10 (38%) of 26 patients with perforation. An echogenic submucosa was noted in 27 (60%) of 45 patients with uncomplicated appendicitis but in only three (30%) of 10 patients with a visible appendix and perforating appendicitis (p < .05). In 19 of 26 patients with perforating appendicitis, sonography showed loculated periappendiceal or pelvic fluid collections; no patient with nonperforating appendicitis had a loculated fluid collection (p < .05). No statistically significant association was found between the presence or absence of perforation and free pelvic fluid, prominent periappendiceal fat, or an appendicolith. CONCLUSION: Our results indicate that sonography can be helpful in the diagnosis of perforating appendicitis. The best predictors of perforation are absence of the echogenic submucosal layer and the presence of a loculated fluid collection.

Acute Disease↗
PubMed2003

Gastro-intestinal tract perforation in neonates.

BACKGROUND: Gastro-intestinal tract (GIT) perforation in neonates is a serious problem associated with high mortality due to resulting sepsis. Co-morbid factors, eg. prematurity, respiratory problems, low birth weight, and nutritional factors, negatively affect the outcome. OBJECTIVES: To review the management outcome of gastro-intestinal tract perforation in neonates in KwaZulu-Natal and identify factors that require attention for better survival of neonates with GIT perforation. DESIGN: Retrospective study of consecutive complete data sets of patients presenting with a diagnosis of GIT perforation. SETTING: Department of Paediatric Surgery, Nelson R. Mandela School of Medicine, University of Natal, Durban, South Africa. SUBJECTS: Fifty four neonates treated for gastro-intestinal tract perforation between January 1998 and January 2003. MAIN OUTCOME MEASURES: Morbidity as determined by complications and mortality. RESULTS: More males (69%) were affected than females (31%). The median birth weight was 2.3 kg and median age at presentation was four days. Eighty nine percent were referred from peripheral hospitals. Abdominal distension was the leading symptom and sign (74%). Co-morbid factors were present in 89%, with prematurity as the leading factor (52%). Necrotising enterocolitis (NEC) was the main cause of perforation (33%) and the terminal ileum was the most common site. Most (56%) were treated by excision and primary repair of perforations. Sepsis was the leading complication (44%) and major cause of death (72%). Mortality was highest (56%) in perforations due to other primary pathology followed by NEC (53%). Overall mortality was 46%. CONCLUSION: It is essential to prevent secondary perforations by early recognition and management of primary pathology. Management of pneumoperitoneum in neonates with respiratory difficulties should be included in resuscitation before transfer. Rectal temperature monitoring and herbal enemas should be strongly discouraged.

Anti-Infective Agents↗
PubMedDate not supplied

Typhoid intestinal perforation in north central Nigeria.

BACKGROUND: Typhoid intestinal perforation is a surgical problem with severe morbidity and high mortality in North Central Nigeria. PATIENTS AND METHODS: In order to determine the pattern and the prognostic indices, we studied 101 patients with typhoid intestinal perforation managed over a ten-year period RESULTS: Children constituted 49% of the cases and majority (78%) of the patients were in the low socio-economic strata. The incidence peaked to 67% between November and March - the dry season in Nigeria. The male/female ratio was 1.9:1 with a mean age of 19 years and a mean hospitalization period of 18 days. There were 167 perforations; four involved the large bowel and appendix, and in 72.2% cases, the perforation was single. The mortality rate was 13.9%, affected mostly children and significantly worsened by prolonged perforation-surgery interval > 72 hours, jaundice, convulsion, ASA V, faecal peritonitis and re-exploration for early intra-peritoneal complications. Morbidity rate was 65.3% and significantly affected more children than adults and associated with perforation-surgery interval of between 24 and 72 hours, haematochezia and multiple perforations. Moribund patients fared better when operated upon under local anaesthesia with adequate analgesia. The least traumatic but effective surgical procedure that could seal the perforations and keep the peritoneum clean gave the best results. Children who survived up to 5 days and adults who survived up to 10 days after surgery had better chances of survival. CONCLUSION: The most significant prognostic factor is late presentation which prolongs perforation-surgery interval and the other complication and mortality indices are directly influenced by it.

Adolescent↗
PubMed2005

Prognostic factors in typhoid perforation.

OBJECTIVE: To discuss the effect of duration of illness before perforation and time interval between perforation and surgery on the prognosis of typhoid perforation. DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Nishtar Hospital, Multan from September 2002 to September 2004. PATIENTS AND METHODS: Seventy-two patients of typhoid perforation were included in this study. The patients were divided into three groups A, B and C according to duration of illness before perforation. In these groups, typhoid perforation occurred during 1st, 2nd and 3rd week respectively. Further patients were divided into group D, E and F according to time interval between perforation and surgery. In these groups surgery was carried out within 24 hours, 24-48 hours and after 48 hours respectively. RESULTS: Fifty-six patients were males and 16 were females. In groups A, B and C, mortality rate was 6.6%, 13.3% and 25%, while morbidity rate was 33.3%, 55.5% and 75% respectively. There were 12, 42 and 18 patients in Group D, E and F with mortality rate of 8.33%, 11.9% and 22.2% respectively. Group D had 41.6% morbidity rate while group E and F had 71.42% and 77.7% respectively. CONCLUSION: In this study, early perforation during the typhoid fever and short perforation-operation interval were good prognostic signs. So best results can be achieved by early patient's presentation and early operation.

Adolescent↗
PubMed2000

Adverse operative risk factors for perforated peptic ulcer.

INTRODUCTION: Mortality from perforated peptic ulcer still remains high as a result of more perforations in the elderly who are generally more ill. We conducted this retrospective study to determine the adverse operative risk factors for perforated peptic ulcers. MATERIALS AND METHODS: Two hundred and six consecutive patients operated for perforated peptic ulcers from 1 January 1993 to 31 December 1997 were reviewed. RESULTS: Majority (n = 194) of the patients had perforations at the pyloroduodenal region and the remaining 10 patients had perforated benign gastric ulcers. The median age at surgery was 58 years (range 18 to 91 years). Forty-four patients (21.4%) were more than 70 years old. The 30-day operative mortality rate was 10.7% (n = 22). Advanced age (> 70 years), female gender, concurrent major medical illness, perforation developed while hospitalised for other medical illnesses, prolonged perforation (> 24 hours) and preoperative hypotension (systolic blood pressure < 90 mmHg) were indicators for operative mortality by univariate analysis. By logistic regression analysis, only concurrent major medical illness, prolonged perforation and preoperative hypotension were independent adverse risk factors. The operative mortality rate for patients with 0, 1, 2 and 3 independent adverse risk factors were 0%, 11%, 30% and 88%, respectively. CONCLUSIONS: As concurrent medical illness is a non-modifiable factor and preoperative hypotension is usually resulting from treatment delay and inadequate resuscitation, emphasis should place on shortening the time to surgery as well as prompt resuscitation.

Adolescent↗
PubMedDate not supplied

Oesophageal perforation after sclerotherapy. Description of a case.

Surgery is considered mandatory for major oesophageal perforations but the operative risk in cirrhotic patients is very high. The best treatment of these perforations is unknown as these have been always analyzed together with all other kinds of oesophageal perforations. A case is reported of spontaneous healing of severe postsclerosal perforation in an aged cirrhotic patient treated conservatively who otherwise should have been treated surgically. Conclusions are that due to the rarity and the cirrhosis, the common guidelines for the treatment of major esophageal perforations are not to be automatically extended to these perforations as postsclerosal perforation is clinically particular, etiologically and prognostically different than all other oesophageal perforations. Conservative but active treatment is to be tried first also with major postsclerosal oesophageal perforations.

Aged↗
PubMed2000

[Esophageal perforations. Presentation of 23 cases].

AIM: Esophageal perforations are the most serious perforations of the digestive tract and their treatment remains controversial. The aim of this study was to analyse the outcome of patients with esophageal perforations given surgical and conservative treatment. PATIENTS AND METHODS: Retrospective study of 23 patients with esophageal perforations, 8 cervical (35%) and 15 thoracic (65%). Medical treatment was indicated in patients who fulfilled Cameron's criteria (minimal signs of clinical sepsis; disruption contained in the mediastinum; drainage of the cavity back into the esophagus; minimal symptoms). The remaining patients underwent surgery. RESULTS: Two patients with cervical perforations (25%) met Cameron's criteria. Evolution after conservative treatment was favourable. The remaining patients (75%) were surgically treated: simple closure of the perforation was performed in four and drainage of the cervical abscess in two. Two of the patients who underwent surgery presented pleural hemorrhage, one of which was associated with pneumonia. Four patients with thoracic perforation (27%) met the criteria for conservative treatment. One presented respiratory distress syndrome during treatment and required intensive care. Evolution was favorable in all. The remaining 11 patients (73%) received surgical treatment: in five (46%) simple closure of the perforation was performed, in three (27%) bipolar exclusion was performed and in the remaining patients, other techniques were used. Morbidity was 82% (nine patients) mainly due to pneumonia and mortality was 46% (five patients). CONCLUSIONS: Treatment of esophageal perforation should be individualized. Conservative treatment should be considered in patients meeting Cameron's criteria as their evolution is favorable, with low morbidity and mortality and surgery is not necessary.

Abscess↗
PubMedDate not supplied

The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age.

BACKGROUND/AIMS: Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of this study is to investigate the operative risk factors and the long-term recurrence rates and to define the optimal surgical procedures in emergency situations in elderly patients. METHODOLOGY: From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforation in 50 patients and a gastric ulcer perforation in 80 patients) were operated on in an emergency situation in our clinic. We investigated the following items; medical illness, preoperative risk factor, optimal surgical procedure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment. RESULTS: A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P = 0.03), heart (P = 0.02), kidney (P = 0.04), and diabetes (P = 0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoperative mortality rate was recorded in patients who underwent a simple closure and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gastric ulcers, the mortality rate in patients with a gastrectomy was significantly higher than in patients with a simple closure. The practical application of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortality rate with the increasing number of risk factors. Based on the 5 postoperative years after treating a perforated duodenal ulcer, the cumulative recurrence rate after a simple closure (63.6%) was significantly higher than that after a simple closure and vagotomy (38.1%) (n = 0.02) or after gastrectomy (0%) (P < 0.001). At 5 years postoperatively, the cumulative recurrence rate after a simple closure (41.2%) was significantly higher than that after a gastrectomy (15.9%) (P < 0.01). CONCLUSIONS: In conclusion, in an emergency situation, elderly patients are in a highly unfavorable prognostic condition due to their advanced age, and comorbidity, which thus leads to poorer results, not only worldwide, but also in Japan. Based on our findings, in duodenal ulcer cases, a simple closure and vagotomy is recommended because of its low mortality and minimal stress, except for cases with a giant perforation measuring over 20 mm in diameter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate.

Age Factors↗
PubMedDate not supplied

Clinical analysis of necrotizing enterocolitis with intestinal perforation in premature infants.

To identify the prognostic factors correlating with the outcome of the perforated necrotizing enterocolitis (NEC), the charts of 20 premature infants with perforated NEC were reviewed. Eight patients had long-term survival and 12 died. Infants in the survival group had significantly lower incidence of starting to feed before perforation, patent ductus arteriosus, indomethacin use, acidosis, and shock. Sepsis was only found in the group of infants that died The survival group were diagnosed with NEC and intestinal perforation at an earlier age than the infants that died. The time from diagnosis of NEC to intestinal perforation was longer in the infants that died. The localization of necrosis from operativefindings were all confined to the ileum-cecum area in survival group. The infants in the survival group were likely to have a single perforation. In addition, according to the operative management, they were divided into three groups: Group I consisted of six patients who received peritoneal drainage only, group II consisted of three patients who received peritoneal drainage followed by laparotomy, and group In consisted of 11 patients who received primary laparotomy. Infants in groups I and II had significantly lower gestational ages and birth weights than group III. There were no significant differences in mortality rates among infants in groups I, II and III. We concluded that the factors including prior enteral feeding, patent ductus arteriosus, indomethacin use, acidosis, sepsis, shock, delayed onset of NEC and perforation, multiple perforation, and diffuse necrotic changes were significant prognostic factors of poor outcome. Peritoneal drainage was a resuscitative procedure in critical condition and laparotomy should mostly be considered as the final treatment in the infants with perforated NEC.

Enterocolitis, Necrotizing↗
PubMedDate not supplied

Laparoscopic versus open surgical closure of perforated duodenal ulcers: a comparative study.

BACKGROUND: Laparoscopic closure of duodenal ulcer perforation may be an alternative to open surgery due to lower morbidity. Most published series have used omental plug for laparoscopic closure. We performed simple closure of the perforation laparoscopically and compared the results with those obtained by open surgery. METHODS: Of 77 consecutive patients with duodenal ulcer perforation 10 were excluded due to their high risk for laparoscopic surgery. 34 (age 18-61 years; one woman) were treated by laparoscopic surgery while 33 (age 23-63 years; two women) underwent laparotomy. Closure of the perforation was achieved by suturing the edges of the perforation. RESULTS: 27 patients had successful closure of perforation by laparoscopy; one had sealed perforation and did not need closure. Conversion to open surgery was necessary in 6 patients (17.8%). Median operating time was 50 minutes (range 25 to 120) and median hospital stay was 4 days (range 4 to 6) for laparoscopy. There was no postoperative leak. Corresponding figures for open surgery were 55 minutes (45 to 75) and 9 days (7 to 13). Patients in the laparoscopy group returned early to work (median 13 days, range 10 to 15 days postoperatively) as against 26 days (21 to 35) in the open surgery group (p < 0.001). CONCLUSION: Laparoscopic closure of duodenal ulcer perforation is safe and effective. It is a better method of treating duodenal ulcer perforation when the patient's condition allows pneumoperitoneum and laparoscopy.

Adolescent↗
PubMedDate not supplied

Factors contributing to releak after surgical closure of perforated duodenal ulcer by Graham's Patch.

BACKGROUND: Perforated duodenal ulcer is one of the common surgical emergencies. Releak after duodenal ulcer perforation closure is an important cause of mortality. This study was planned to analyse risk factors if any, which could predict releak following duodenal ulcer perforation closure and to ascertain the contribution of releak towards ultimate outcome. METHODS: A prospective study was undertaken between September 1997 and August 1999 including all patients undergoing surgery for perforated duodenal ulcer. All patients (119) underwent a Graham's patch closure and were put on parenteral H2 antagonists and antibiotics postoperatively. Patients with releak were included in case group (9), and those without releak were included in control group (110). Factors considered for comparison among the two groups were age, pulse rate, systolic blood pressure at presentation, anthropometeric parameters, haemoglobin, serum total protein/albumin, total lymphocyte count and operative findings including size of perforation, evidence of chronicity of ulcer, quantity and nature of peritoneal fluid. RESULTS: Age greater than 60 years (p-0.0470, CI-0.76-31.54), pulse rate greater than 110/minute (p-0.0217, CI-1.04-34.48), systolic blood pressure less than 90 mm Hg (p-0.0016, CI-2.04-71.9), haemoglobin level less than 10 g/dl (p-0.0009, CI-2.25-135.02), serum albumin less than 2.5 grams/dl (p-0.0145, CI-1.21-38.31), total lymphocyte count less than 1800 cells/mm-3 (p-0.0003, CI-8.9-42.2), size of perforation greater than 5 mm (p-0.0011, CI-1.09-36.13) were identified as risk factors for releak. Serum albumin, hemoglobin and size of perforation were independent risk factors for prediction of releak on multivariate analysis. The anthropometric parameters namely mean triceps skin fold thickness, mean mid arm circumference and mean body mass index were all significantly less in cases as compared to controls. Releak was found to be a significant cause of death in patients with perforated duodenal ulcer. A total of 8 patients died in both the groups. The mortality rate in the releak group was 55.6% (5 out of 9 patients) compared to 2.7% (3 out of 110 patients) in the control group [p-0.0001]. CONCLUSION: Releak was a significant factor influencing mortality rate after omental patch closure of perforated duodenal ulcer.

Adult↗
PubMed2003

[Analysis of 16 cases of uterine perforation during hysteroscopic electro-surgeries].

OBJECTIVE: To analyse the cause, diagnosis, treatment and preventive methods of uterine perforation resulting from hysteroscopic electro-surgeries. METHODS: Data of cases with uterine perforation were collected from 5 hospitals where overall 3,541 hysteroscopic electro-surgeries were done from May 1990 to July 2002. There were 1 468 transcervical resections of endometrium (TCRE), 797 cases of transcervical resection of myoma (TCRM), 783 cases of transcervical resection of endometrial polyp (TCRP), 189 cases of transcervical resection of uterine septa (TCRS), 112 cases of transcervical resection of uterine adhesion (TCRA) and 192 cases of transcervical removal of foreign body (TCRF). All operations were performed under B-ultrasonographic or laparoscopic monitoring. Cervical dilator stick was inserted into cervical canal or 200 micro g of misoprostol put in the posterior fornix the evening before operation. The procedures were done according to different indications and purposes. Cases of uterine perforation were divided into two groups: caused by approaching (entry-related) and by surgical instruments (technique-related). RESULTS: Totally sixteen cases (0.45%) of uterine perforation occurred. Seven cases occurred during cervical dilatation and 1 during hysteroscopy inserting lentry-related. Eight cases were technique-related caused by electrode. The incidences of uterine perforation of different operations were: TCRA 4.46% (5/112), TCRF 3.12% (6/192), TCRE 0.27% (4/1 468), TCRM 0.13% (1/797). TCRP and TCRS none. These 16 cases were all diagnosed during operations. 10 cases (62%) by B ultrasound and (or) laparoscopy, 6 cases (38%) by hysteroscopy and clinical features. 13 cases were complete uterine perforations, among them 2 were diagnosed by laparoscopic monitoring, 5 by B-ultrasonic monitoring, 4 by hysteroscopy and 2 by symptoms and B-ultrasound, 3 cases were incomplete uterine perforations in which 2 were diagnosed by laparoscopic monitoring and one by B-ultrasound monitoring. CONCLUSIONS: Half of uterine perforation cases were entry-related, so attention has to be paid to entry of Hegar or hysteroscopy (i.e., not dilate the cervix as possible and introduce the scope under direct vision). The other half were related to surgeons' experience and type of operation. TCRA and TCRF run more risks. B-ultrasound and (or) laparoscopy monitoring during hysteroscopic electro-surgery may help to prevent but not completely avoid uterine perforation.

Adult↗
PubMed1960

Serum amylase in peptic gastroduodenal perforation. A study to determine the significance of abnormally high levels.

Elevated serum amylase is a frequent concomitant of perforated gastroduodenal ulcer. To determine if there might be significant correlation between an increase in amylase and some of the other factors associated with ulcer perforation, a study was made of the clinical records of 1,000 patients with perforation of gastroduodenal ulcers. Sixteen per cent of the patients had amylase levels of 200 Somogyi units or more. This rise in serum amylase comes about in cases of perforated peptic ulcer as a result of peritoneal lymphatic absorption of fluid containing pancreatic enzyme which is spilled through the perforation. Among patients with perforated ulcers and elevated serum amylase levels, the higher the amylase level, the higher the mortality rate. The factors of amount of abdominal fluid spill, the duration of the perforation before surgical closure, the size of the perforation, shock and recent ingestion of food were also studied for possible relationship with elevated serum amylase. All appeared to be statistical if not etiological associates of abnormal serum amylase levels. Because high amylase values so often occur in perforated ulcer, there is no amylase level that can be considered diagnostic of acute pancreatitis.

Amylases↗