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PubMed1977

Resection of the perforated segment. A significant advance in treatment of diverticulitis with free perforation or abscess.

As a result of improved medical management of chronic diverticular disease, perforation has become the most common indication for surgical intervention. During the past five years sixty-three patients underwent operation for colonic diverticular disease, of which forty-six were for perforation (generalized peritonitis in 8, abscess in 30, and fistula in 8). The eight patients with generalized peritonitis underwent emergency exploration for spreading peritoneal signs and were managed by resection of the perforated segment, end colostomy, and mucous fistula or Hartmann's pouch. Treatment of thirty-eight patients with abscess or fistula has also stressed primary resection of the perforated segment of colon. Resection and end colostomy without anastomosis was performed in three. Primary anastomosis with proximal diverting colostomy was performed in four. Primary anastomosis alone was done in thirty-one patients. There were no deaths. These results support primary resection of the involved colon with immediate or delayed anastomosis in the operative management of perforated diverticular disease.

Abscess↗
PubMed2006

Idazoxan increases perforant path-evoked EPSP slope paired pulse inhibition and reduces perforant path-evoked population spike paired pulse facilitation in rat dentate gyrus.

Norepinephrine, acting via beta-adrenoceptors, enhances the perforant path-evoked potential in dentate gyrus. Using systemic idazoxan to increase norepinephrine, and paired perforant path pulses to probe early inhibition, previous investigators reported that idazoxan increased initial spike amplitude and increased somatic feedback inhibition. Here, feedback inhibition was re-examined in idazoxan-treated (5 mg/kg) rats under urethane anesthesia. To control for initial increased spike amplitude after idazoxan, evoked potentials were matched, pre- and post-idazoxan, on initial population spike. Input-output current profiles were also compared pre- and post-idazoxan. Saline- and timolol-filled micropipettes permitted evaluation of a contribution of local beta-adrenoceptors. As previously observed, initial spike amplitude was potentiated by idazoxan. Comparable spike potentiation was not seen on the timolol micropipette. Paired pulse inhibition of spike amplitude apparently increased, but input-output curve comparisons revealed a loss of feedback facilitation rather than an increase in feedback inhibition. Initial EPSP slopes were depressed after idazoxan in input-output curve data. EPSP slope feedback ratios were significantly reduced following idazoxan. These data suggest idazoxan has multiple effects on perforant path input to the dentate gyrus. Spike potentiation following idazoxan has previously been shown to depend on intact norepinephrine input. Here, the reduction in spike potentiation on the timolol pipette is consistent with other evidence that norepinephrine-mediated potentiation of the perforant path-evoked potential is dependent on local beta-adrenoceptor activation. The input-output data suggest a decrease in feedback facilitation after idazoxan is likely to account for the apparent increase in feedback inhibition previously reported. Decreased EPSP slope ratios with similar paired pulse intervals have been reported in novel environments. Since exposure to novel environments activates locus coeruleus neurons, norepinephrine may mediate the change in EPSP slope inhibition reported in awake rats. In summary, these results are consistent with the hypothesis that idazoxan potentiates granule cell responses to perforant path input in the dentate gyrus via increases in norepinephrine that lead to beta-adrenoceptor activation, and, further, that idazoxan reduces paired pulse feedback spike facilitation and enhances EPSP slope, but not spike, feedback inhibition.

Adrenergic alpha-Antagonists↗
PubMed2002

Surgical management of esophageal perforation: role of esophageal conservation in delayed perforation.

Definitive repair of esophageal perforation is considered the preferred treatment for patients presenting early (<24 hours). However, the optimal management of delayed presentation (>24 hours) has not been well defined. This study examined the management of esophageal perforation and compared the outcomes of early versus delayed presentation. Records of patients admitted with the diagnosis of esophageal perforation were reviewed. Contrast studies were used to confirm the diagnosis in all cases. Patient demographics and outcome were analyzed to determine differences between early and delayed presentation. A total of 22 cases of esophageal perforation were identified (eight early vs 14 delayed presentations). Operative interventions included primary repair (four), reinforced repair (14) either with intercostal muscle or pleural flap, and a complete esophageal resection (one). Debridement and drainage without repair were done in two patients and a proximal intramural tear was treated with antibiotics and observation. Two patients died during hospitalization. All surviving patients had near-normal restoration of esophageal function. Follow-up at 3 years has shown minimal gastrointestinal problems. One patient required repeat esophageal dilatations and two patients underwent antireflux therapy. Esophageal repair should be considered in all cases of nonmalignant esophageal perforation and should not be influenced by the time of presentation.

Debridement↗
PubMedDate not supplied

[Comparison of long-term course of perforating and non-perforating Crohn disease].

OBJECTIVES: To evaluate the influence of the indication of the first surgical procedure on the prognosis of Crohn's disease. METHODS: We compared retrospectively the long-term course of 179 patients operated on for a perforating disease and 322 patients operated on for a nonperforating disease. Mean follow-up was 11 years and 2 months in the two groups. RESULTS: Forty of 179 (25%) and 106 of 322 (33%) patients with perforating and nonperforating diseases underwent a second intestinal resection, respectively. The patients who had been operated on for a perforating disease were significantly more often reoperated on for the same indication, and conversely. Patients with perforating diseases experienced less second resections (actuarial rates: 37 +/- 11% vs 51 +/- 8% at ten years respectively), less post-surgical handicaps (mean index 24.9 vs 27.9), and fewer patients required immunosuppressive drugs (25 vs 35%). CONCLUSION: Long-term prognosis of perforating Crohn's disease does not appear to be more severe than that of nonperforating disease.

Adult↗
PubMed2000

Anatomical features of perforator blood vessels in the deep inferior epigastric perforator flap.

The anatomical basis of the blood supply to the deep inferior epigastric perforator (DIEP) flap and the circulation of the cutaneous territory zone IV have been studied in 40 anatomical dissections on fresh cadavers. The pedicle length, diameter and the number and distribution of the major perforator vessels were recorded. The cutaneous territories supplied by the perforator vessels were studied by injecting blue dye in the pedicle of ten specimens. In addition, intravital blue dye studies were performed by injecting the largest perforating vessel of five patients at abdominoplasty. The resulting cutaneous staining was recorded. The deep inferior epigastric artery was present in all cadaver dissections with an average length of 10.3 cm (range 9.0-13 cm) and an average diameter of 3.6 mm (range 2.8-5.0 mm). There were consistently one or two major perforator vessels for each pedicle, located within a radius of 8 cm below the umbilicus. The results of the injection study revealed cutaneous staining of zones I-III. Zone IV was stained weakly or not at all. The same findings were obtained in the clinical cases of abdominoplasty. Zone IV must be critically assessed in clinical cases of the DIEP flap.

Abdomen↗
PubMed2006

Thin anterolateral thigh perforator flap using a modified perforator microdissection technique and its clinical application for foot resurfacing.

BACKGROUND: A thin skin flap is often required for optimal resurfacing of particular areas of the body. An anterolateral thigh perforator flap can be thinned to an extent to which it is vascularized by the subdermal plexus only. This study presents a novel flap thinning technique and its application for resurfacing the dorsum of the foot. METHODS: From July of 2002 to October of 2003, 18 patients underwent resurfacing of the dorsum of the foot with thin anterolateral thigh flaps. The main perforators were strategically located in the flap center to keep the peripheral area within the vascular territory. The flaps were larger than needed, initially elevated subfascially, and then thinned to the suitable thickness while the pedicle was still attached. The dissection of perforators in the adipose layer close to the dermis entry was carried out microscopically. Flap sizes ranged from 3 x 3 to 16 x 8 cm. RESULTS: Seventeen flaps survived completely and one had distal superficial necrosis of 1 x 2 cm. No debulking procedures were necessary. Average follow-up was 12 months. CONCLUSIONS: A thin flap vascularized through subdermal plexus is reliable. Microsurgical dissection of the perforator is a recommended technique. The thin anterolateral thigh perforator flap provides ideal reconstruction in resurfacing the dorsum of the foot.

Adolescent↗
PubMed2003

Free gluteal artery perforator flap with a short, small perforator.

The introduction of supermicrosurgery has led to the development of a new gluteal perforator flap nourished only by a musculocutaneous perforator of the superficial gluteal artery system. This flap has a perforator that is short (3-4 cm in length) and small (less than 1 mm). The successful transference of a free gluteal perforator flap for the coverage of soft-tissue defects in the foot and face in two patients is described in this article. With this flap, deeper and longer dissection for a pedicle vessel is unnecessary, flap elevation time is shorter, thinning of the flap with primary defatting and creation of an adiposal flap with customized thickness for tissue augmentation are possible, the donor site is in a concealed area with minimal donor site morbidity, and application of the flap as a scarred flap for previous operations in the gluteal region is possible. The disadvantages of this flap are necessity of dissection for a smaller perforator and of anastomosis of small-caliber vessels of less than 1.0 mm.

Adult↗
PubMed2005

Duplex ultrasound imaging in free transverse rectus abdominis muscle, deep inferior epigastric artery perforator, and superior gluteal artery perforator flaps: early and long-term comparison of perfusion changes in free flaps following breast reconstruction.

OBJECTIVE: Our objective was to assess the hemodynamic differences in free DIEP (deep inferior epigastric artery perforator flap), S-GAP (superior gluteal artery perforator flap) flaps versus TRAM (transverse rectus abdominis muscle) flaps and to analyze any perfusion change due to perforator dissection (study 1). To examine the hypothesis as to whether flap perfusion is maintained through the pedicle (study 2), we also compared short- and long-term DIEP flap perfusion. MATERIAL AND METHODS: Blood volume flow, velocity, and diameter of the donor and recipient vessels of 4 TRAM flaps, 5 S-GAP flaps, and 17 DIEP flaps were examined preoperatively on day 5 and also 18 months postoperatively using duplex ultrasound. RESULTS: The greatest volume flow and velocity are measured in the TRAM flaps, followed by S-GAP and DIEP flaps. Blood flow in the musculocutaneous and perforator flaps is twice as great as in the donor vessels, which is proof of flap hyperperfusion. SUMMARY: The minimum perfusion requirement is easily satisfied in musculocutaneus and free perforator flaps. In the long term, DIEP flap perfusion increases 13%, which assumes that DIEP flap perfusion is maintained on the pedicle.

Anastomosis, Surgical↗
PubMedDate not supplied

Endothelial reaction to perforating and non-perforating excimer laser excisions in rabbits.

With an ArF excimer laser (193 nm, 750 mJ/cm2, 20 Hz) and a special slit-mask system, perforating and non-perforating linear keratectomies were performed in 55 rabbit corneas with a follow-up from 1 hour to 6 months. Varying the pulse number according to ablation rate (0.8 micron/pulse) and corneal thickness, four linear radial excisions (3 mm length, 70 microns width) of increasing depth (70%, 80%, 90%, 100% perforation) were produced. The corneas were processed for light microscopy, scanning and transmission electron microscopy, and vital staining of the endothelium. Except for mild cell contact alterations and discrete single cell damage in the 90% deep excisions, no endothelial damage could be detected after non-perforating keratectomies. Minute (less than 20 microns) and small (20 to 100 microns maximal diameter) perforations induced cell enlargement, formation of pseudopodia, rosette-like figures, multi-nucleated giant cells, and ultimately uniform reformation of the cell pattern (1 hour to 7 days postoperatively). Larger excimer laser defects of Descemet's membrane (greater than 100 microns) were overgrown by dedifferentiated endothelial cells producing a new PAS-positive basement membrane. Vital staining revealed the complete and stable reorganization of the endothelium over these lesions within 6 months. Our observations are similar to those reported on the endothelial repair process following other surgical manipulations (knife incisions, direct Nd:YAG-laser trauma) and support the applicability of excimer lasers for corneal trephination in patients.

Animals↗
PubMed1989

[Use of a fibrin glue (Tissucol) for treating perforated or pre-perforated corneal ulcer].

Treatment of perforated and preperforated corneal ulcers is a difficult task. As emergency penetrating keratoplasty results in poor visual outcome, surgical glue has been suggested as an alternative solution, but poor corneal tolerance for cyanoacrylate made this treatment non satisfactory. We treated 15 corneal ulcers (11 perforations, 2 descemetoceles and 2 deep ulcers) with a fibrin glue. Cicatrisation was obtained in 14 cases by this technic. In one case, cicatrisation was not satisfactory and penetrating keratoplasty was performed 3 days later. This method permits healing of the corneal perforation without the necessity of performing penetrating keratoplasty either if the perforation is distant from the visual axis or if penetrating keratoplasty is contraindicated. In other cases it permits a later penetrating keratoplasty to be performed an a quiet eye. We think this technic can be useful in corneal perforations less than 2 mm in diameter and in chronic deep ulcers difficult to heal.

Corneal Ulcer↗
PubMed2000

[Perforated duodenal ulcer: laparoscopic treatment of perforation and ulcerous disease].

STUDY AIM: The aim of this retrospective study was to report a continuous series of 44 perforated duodenal peptic ulcers operated on through laparoscopic approach with curative treatment of the peptic ulcer disease for socioeconomic purpose. PATIENTS AND METHOD: From February 1995 to May 1996, 44 patients were operated on laparoscopically. There were 42 men and two women (mean age: 36 years). All patients had peritonitis with pneumoperitoneum in 68%. Duodenal peptic ulcer was known in 12 patients and antecedent of episodic epigastric pain were present in 27. Four trocads were used. The diagnosis was confirmed by abdominal exploration and peritoneal lavage was performed with physiological serum. RESULTS: The procedures were: suture of perforated ulcer associated with posterior vagotomy and anterior seromyotomy (n = 6), with troncular vagotomy and pyloroplasty (n = 24) and single suture (n = 1). A conversion into laparotomy was necessary in 13 patients (29.5%). There was no mediastinitis, no postoperative death. Peritonitis by leakage occurred in two patients who were reoperated by laparotomy; mean duration of hospital stay was 5.5 days. With a one-year follow-up, all patients were in good condition, free of pain. CONCLUSION: With laparoscopic surgery, diagnosis of peptic ulcer perforation was confirmed, peritoneal lavage was perfectly done, duodenal perforation was sutured and surgical treatment of the peptic ulcer disease was performed, which is important in poor countries.

Adult↗
PubMed2001

Application of N-methyl-D-aspartate induces long-term potentiation in the medial perforant path and long-term depression in the lateral perforant path of the rat dentate gyrus in vitro.

The effect of application of N-methyl-D-aspartate (NMDA) on synaptic plasticity was studied in the medial and lateral perforant path-granule cell synapse in the outer blade of the dentate gyrus in vitro. Field excitatory post-synaptic potentials were recorded from the middle or outer molecular layer in response to stimulation of the medial or lateral perforant path. Bath perfusion of NMDA (10 microM, 5 min) resulted in induction of long-term potentiation in the medial perforant path, and induction of long-term depression in the lateral perforant path.

Animals↗
PubMedDate not supplied

Traumatic bowel perforation: analysis of CT findings according to the perforation site and the elapsed time since accident.

Abdominal CTs of 57 patients with bowel perforation after blunt abdominal trauma were retrospectively analyzed to determine: the diagnostic accuracy of the perforation site, and the differential findings according to the elapsed time from the trauma. Diagnostic accuracy of the perforation site was as follows: duodenum (100%), jejunum (81%), jejunoileal junction (100%), ileum (93%), and colon (20%). Extraluminal air was the only significant differential findings according to the elapsed time, and was seen more commonly on late stage of bowel perforation (P<.05).

Abdominal Injuries↗
PubMedDate not supplied

Efficacy of nutritional therapy for perforating and non-perforating Crohn's disease.

BACKGROUND/AIMS: Enteral nutrition is the currently established primary therapy for Crohn's disease in Japan. We examined the effects of postoperative nutritional therapy in patients with perforating type and non-perforating type Crohn's disease. METHODOLOGY: We retrospectively reviewed the records for 218 patients who underwent surgical interventions for Crohn's disease in our hospital between January 1, 1974 and September 30, 2001. They were divided into four groups: 92 patients in the non-perforating type (NP type) + Elemental Diet (ED) group had received ED therapy and nutritional education, 22 patients in the NP type + NoED group had not received ED therapy or nutritional education, 88 patients in the perforating type (P type) + ED group and 16 patients in P type + NoED group. We evaluated the incidence of reoperation rate for each group. RESULTS: Patients with a postoperative ED therapy demonstrated a significant decrease in the incidence of second resection. The incidence of second resection in the NP type + ED group was significantly lower than that of the other groups. The NP type + NoED group and the P type + ED group followed similar courses. CONCLUSIONS: In patients with Crohn's disease postoperative ED therapy and nutritional education is effective in reducing the incidence of second resection. It appears that postoperative ED therapy and nutritional education is more important in patients with P type Crohn's disease.

Adolescent↗
PubMedDate not supplied

[Perforation in Crohn's ileitis and its consequences in the natural history of disease. 2. Consequences of perforation in the peritoneal cavity: diffuse septic peritonitis, abscesses, external and internal fistulas].

Perforation of Crohn's ileitis occurring in the peritoneal cavity is always free perforation, but it causes usually a localized peritonitis, i.e. an abscess, and only in rare cases a diffuse septic peritonitis for the reasons expounded in the Part 1. Diffuse septic peritonitis has the common features of all perforative peritonitis; its surgical treatment must be ileocolic resection, simple suture of perforation being a serious mistake. Abscesses develop: as regards the ileum, about 30-45 cm from the ileo-caecal valve; as regards the abdominal cavity, in the right iliac fossa or in the pelvis, at a site where the ileum, weighed down by its chronic inflammation, rests. These abscesses have a wall like that of all abscesses, with no specific crohnian features. On operation, if technical considerations so require, part of the abscess wall may be left in place with no fear of recurrences or fistulas. Nowadays, most abscesses of the right iliac fossa are opened surgically; an enterocutaneous fistula follows. Most abscesses of the pelvis still open spontaneously into a hollow organ (sigma-rectum, urinary bladder), and rarely into the vagina or onto the perineum after penetrating through the levator any muscle and causing suppuration of the ischiorectal fossa.

Abdominal Abscess↗
PubMed1983

Neonatal gastric perforations; a diagnostic clue in pre-perforative phase.

This paper is a retrospective analysis of the pre-perforative clinical picture in twenty-seven neonates with gastric perforations. In fifteen there was a remarkably consistent progressive pattern in the preperforative clinical course. We separated the clinical course of the disease into three distinct stages in relation to pathological changes in the gastric wall i.e. gastric ischemia and dysfunction, transmural peritonitis and paralytic ileus, and actual perforation. Emphasis was placed on the existance of a clinically detectable pre-perforative phase which, if interpreted correctly, should lead to earlier diagnosis and consequently more satisfactory therapeutic results.

Hematemesis↗
PubMed1993

Activation of the medial septal area attenuates LTP of the lateral perforant path and enhances heterosynaptic LTD of the medial perforant path in aged rats.

Age-related memory impairments may be due to dysfunction of the septohippocampal system. The medial septal area (MSA) provides the major cholinergic projection to the hippocampus and is critical for memory. Knowledge of the neurobiological mechanisms by which the cholinergic system can attenuate age-related memory loss can facilitate the development of effective cognitive enhancers. At present, one of the best neurobiological models of memory formation is long-term potentiation/long-term depression (LTP/LTD). In previous studies, intraseptal infusion of the muscarinic agonist oxotremorine, which excites MSA neurons, improved memory in aged rats. The present study examined LTP and LTD in aged Fisher 344 rats following intraseptal infusion of oxotremorine. LTP and LTD were assessed using the slope of the EPSP recorded from the hilar region of the dentate gyrus. Induction of LTP was blocked in the lateral perforant path, but not in the medial perforant path, following intraseptal infusions of oxotremorine. The generation and amplitude of heterosynaptic LTD was enhanced in the medial perforant path, but not in the lateral perforant path. The results provide evidence that pharmacological activation of the MSA can modulate LTP and LTD in the hippocampus of aged rats. The implications of these results with respect to memory and synaptic plasticity in the hippocampus are discussed.

Aging↗
PubMed1993

A case of vessel perforation during interventional neuroradiological procedure. Operative findings of the perforated vessel.

A case of vessel perforation by a guide wire during an interventional neuroradiological procedure is reported. The patient was a 59-year-old woman with a left frontal basal arteriovenous malformation (AVM) fed by the left anterior cerebral artery. Transarterial embolization of the AVM was attempted. During the procedure, vessel perforation by the guide wire occurred at the left A1-A2 junction and resulted in subarachnoid hemorrhage, which stopped spontaneously. The patient developed progressive obstructive hydrocephalus, and surgical treatment was performed. The AVM was totally removed after ventricular drainage, and the arterial perforation site was explored. When clot around the left A1-A2 junction was removed, hemorrhage recurred. This hemorrhage was similar to what has been observed when a small perforating artery was avulsed. The hemorrhage site was coagulated under temporary occlusion of both A1 segments. Surgical intervention was probably not necessary for this type of bleeding if it had stopped spontaneously, because the rebleeding from the small pinhole would be unlikely, and the operation was more hazardous than the usual aneurysmal surgery.

Cerebral Arteries↗