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PubMedDate not supplied

Perforation of the oesophagus. A comparison between surgical and conservative treatment.

A series of 48 patients with oesophageal perforations was reviewed retrospectively. Eighty-seven per cent of the perforations were iatrogenic. Twenty-four patients were treated conservatively; 3 of this group died. The other 24 patients were treated surgically and 4 of them died. Patients with alarming symptoms and/or a large perforation underwent operative treatment unless there were contra-indications. Retained foreign bodies after perforation, and malignancy in the perforation area, were considered as indications for operation. Conservative treatment was reserved for patients with minor tears combined with a less turbulent course. The interval between perforation and therapy was not of decisive importance for the mortality in our series. The clinical picture, which was dominated by chest pain, gave the earliest indication of perforation, while the responses of the sedimentation rate, temperature and white blood count occurred later and were less reliable diagnostic signs.

Adolescent↗
PubMedDate not supplied

Bowel perforation as a presenting feature of pheochromocytoma: case report and literature review.

OBJECTIVE: To report a case of colonic perforation as the initial manifestation of pheochromocytoma and discuss the underlying pathophysiologic mechanism. METHODS: The clinical, biochemical, radiologic, and pathologic findings are described. In addition, the management of the patient is discussed and the relevant literature reviewed. RESULTS: A 57-year-old man presented with large bowel perforation after pseudo-obstruction. Emergency laparotomy revealed two cecal perforations but no obstructing lesion; however, hypertension persisting postoperatively raised the suspicion of pheochromocytoma. This diagnosis was confirmed by measurement of 24-hour urinary hydroxymethylmandelic acid excretion and computed tomography of the abdomen. The tumor was subsequently resected without complication or recurrence of bowel symptoms. The pathophysiology of bowel perforation in patients with pheochromocytoma is not entirely clear but most likely involves bowel ischemia and necrosis as a result of mesenteric vasoconstriction. This setting coupled with increased intraluminal pressure as a consequence of pseudo-obstruction may cause perforation. CONCLUSION: Bowel perforation in patients with pheochromocytoma is rare and thought to be a consequence of intestinal ischemia and altered motility. This is potentially a life-threatening complication, particularly if the tumor remains undiagnosed and an emergency surgical procedure is necessary. Pharmacologic treatment of pheochromocytoma during pseudo-obstruction may prevent subsequent perforation. Clinicians should be aware of the potential gastrointestinal presentation of this tumor.

Abdomen↗
PubMed1999

Perforated appendicitis is not a contraindication to laparoscopy.

Recent studies have reported an increased risk of intra-abdominal abscess formation following laparoscopic operation for perforated appendicitis. We undertook this study to compare laparoscopic versus open appendectomy in the treatment of perforated appendicitis. Records of all patients undergoing an appendectomy between January 1994 and June 1997 were reviewed, classifying appendicitis as acute, gangrenous, or perforated based on the intraoperative findings. Operative procedures were categorized as open, laparoscopic converted to open, or laparoscopic. The study group included 690 patients; four hundred fourteen (60%) were acute, 77 (11%) were gangrenous, and 199 (29%) were perforated. Although mean length of stay was shorter for all patients undergoing laparoscopic appendectomy, patients with perforated appendicitis had similar length of stay between treatment groups. Mean operative time for open appendectomy was significantly shorter than for converted or laparoscopic appendectomy regardless of diagnosis (P<0.01). Ten patients (1.4%) developed an intra-abdominal abscess: six after open appendectomy (1.7%), one after converted appendectomy (3.7%), and three after laparoscopic appendectomy (1%). There was no significant difference in rate of abscess formation in patients with perforated appendicitis undergoing open, converted, or laparoscopic appendectomy. We conclude that laparoscopic appendectomy for perforated appendicitis is not associated with an increased rate of intra-abdominal abscess formation.

Adolescent↗
PubMed1999

A report of three cases with an oesophageal perforation treated with a coated self-expanding stent.

A perforation of distal oesophagus in benign cases occurs usually as a complication of endoscopic procedures or due to perforating external trauma. Perforations caused by blunt trauma are rare and usually involve high-energy accidents. The time of diagnosis, severity of the perforation, degree of mediastinal and pleural contamination and treatment are the most important factors predicting the outcome. Treatment may be conservative, comprise primary suturation or include oesophageal resection. We present three cases with a benign oesophageal perforation, which we have treated with a coated stent. One of the cases suffered from a thoracic oesophageal perforation due to a lesser trauma, while the other two cases are perforations caused by complications of endoscopy.

Aged↗
PubMedDate not supplied

[Drainage of the abdominal cavity and complications in perforating appendicitis in children].

INTRODUCTION: Controversies regarding drainage and irrigation with antibiotics following perforated appendicitis still exist in literature. Some authors concluded that undrained patients treated with systemic antimicrobial therapy, adequate fluid resuscitation, emergency appendicectomy, peritoneal lavage and primary abdominal wall closure are less exposed to complications. On the other hand, Lund and Murphy and Schwartz and Tapper are still advocating transperitoneal drainage. In that context the aim of this study was to contribute to the current debate with its original results and conclusions. MATERIAL AND METHODS: A series of 56 children, who were operated on for perforated appendicitis during 1996 in Children's Hospital Podgorica and Pediatric Surgery Department of Hospital in Novi Sad, are reviewed. The average age of children in this series was 9.8 years (range, 2-14 years). All children were divided in two groups: patients included in the first group (n = 36) were treated with aggressive fluid resuscitation, preoperative triple antibiotic therapy, peritoneal lavage, avoidance of transperitoneal drains except those used for well-localized abscesses, primary wound closure and postoperative antibiotic therapy for seven to ten days. In the second group, children were managed in the same way, but silicon tube drainage after appendicectomy was included as well. Patients in both groups were given the same antibiotic therapy: intravenous metronidazole combined with gentamicin and ampicillin. RESULTS: Perforated appendicitis most frequently occurred in the age group between 8 and 15 years (77%), with highest incidence in male children (61%) of all children observed. Positive cultures were obtained from peritoneal swabs from 32 children (57%), of which all had pure growth of aerobes (Escherichia coli and Pseudomonas aerugionosa, mixed or pure). 36 children were managed by appendectomy followed by peritoneal lavage using a large amount of saline, and intravenous antibiotic therapy (undrained group), while the other 20 children were treated by appendectomy with silicon tube drainage and the same systemic antibiotic therapy (drained group). A minor complication rate was 43%; this includes 20 cases of wound infection and 4 cases of wound dehiscence. Major complications rate was 5%, which includes 3 cases of ileus. The mortality rate was zero. A comparison of the group that underwent drainage with undrained group showed a relative rate of wound infection to be 19% (undrained) vs. 65% (drained). According to the x2 test, this can be considered a significant difference, with Yates' correction. Wound dehiscence and ileus were more frequent in the drained group: 10% vs. 6% and 19% vs. 3%, respectively. DISCUSSION: The principal factors contributing to perforation of appendix are: age of children, delays of surgical intervention, family anamnesis, social group and late recognition of symptoms of appendicitis. Fast and adequate surgical intervention followed by adequate antibiotic therapy successfully resolve the cases of perforated appendicitis. The rate of serious post-appendectomy complications of 5-10% established by this study, can be considered as acceptable based on standards presented in the relevant literature. Regarding the reduction of wound infections following perforated appendicitis in children, aggressive therapy consisting of aminoglycosides combined with metronidazole have proven to be very efficient. Complications developed more frequently in the group of drained patients. Our results are in accordance with that achieved by authors cited in introduction: undrained patients are less prone to complications in comparison to drained patients. CONCLUSION: We achieved our lowest rate of serious complications following surgery for pediatric perforated appendix with the use of broad-spectrum antibiotic therapy, primary wound closure and without drainage. Regarding our results, we could propose the same treatment protocol to all in

Adolescent↗
PubMed2000

[Treatment of perforated duodenal ulcer by laparoscopy. 35 cases].

OBJECTIVE: Laparoscopic treatment of perforated duodenal ulcer is an alternative to laparotomy. We reviewed our experience to determine feasibility and reliability of the surgical procedure and the subsequent morbidity and mortality. PATIENTS AND METHODS: This was a retrospective series of 35 patients who underwent laparoscopic repair of perforated duodenal ulcers between January 1994 and November 1999. The perforation was closed by interrupted sutures in 86% of cases associated with irrigation-suction of the abdominal cavity. RESULTS: Two complications were observed: pyloric stenosis in one patient with a large perforation and Douglas pouch abscess in another. Conversion to laparotomy was necessary in 8 cases: in 2 of them the edges of the perforation were fragile, in 3 the perforation could not be identified (posterior position), and in 3 intraabdominal adhesions were important. There were no deaths. The 2-year results are quite satisfactory. CONCLUSION: This study shows that the laparoscopic procedure is reliable and adapted to treat ulcer perforation if the size is less than 1 cm.

Adolescent↗
PubMed2000

[Ileus and intestinal perforation in premature infants--current trends in diagnosis and treatment].

OBJECTIVE OF STUDY: a) assessment of the relationship between ileus of premature infants and the development of intestinal perforation in premature infants, b) suggestions of an optimal therapeutic procedure. In the study children (n = 50) are included a) with intestinal perforation in conjunction with impaired excretion of meconium (n = 22), b) with an ileus state based on obstruction of the ileum by a viscous meconium treated either surgically or conservatively (n = 28). Surgical treatment involved: a) establishment of a double ileostomy (n = 28), b) insertion of a T drain into the terminal ileum (n = 8), c) removal of meconium from the gut and its primary closure (n = 2). Conservative treatment in 11 children involved irrigography with an liquid contrast substance under X-ray control. The group of children with perforation was compared with the group of children without perforation, risk factors were evaluated by statistical methods. The necessity of ventilation (P = 0.051) and gestation age (P = 0.006) proved to be statistically significant risk factors for the development of perforation. Survival was not influenced by perforation. All 11 children treated conservatively survived, of 39 operated children 26 survived (66.7%). An early start of conservative treatment of ileus of premature infants reduces markedly the risk of intestinal perforation and can thus influence the survival of low birth weight neonates.

Female↗
PubMed2001

Laparoscopic repair of colonic perforation associated with colonoscopy: use of passing sutures and endoscopic linear stapler.

Laparoscopic surgery recently has been conducted to repair colonic perforation that is associated with colonoscopy. The authors describe their laparoscopic repair of perforation using passing sutures and an endoscopic linear stapler. One 12-mm and several 5-mm trocars were inserted in the lower abdomen under general anesthesia. Observing with a laparoscope, passing sutures were threaded transversely through all layers of the margin of defect and pulled up with forceps to hold the margin straight, along which the defect was stapled with an endoscopic linear stapler. The authors applied this method for five patients, where the perforation occurred in the sigmoid colon or in the cecum (perforation size ranging from 10 mm to 50 mm). Perforation was successfully repaired in all patients, with no complications because of perforation or the procedures. The current method is beneficial because the perforated lesion is safely and easily closed and postoperative colonic stenosis is avoided.

Aged↗
PubMed2001

Outcome of perforated necrotizing enterocolitis in the very low-birth weight neonate may be independent of the type of surgical treatment.

Perforated necrotizing enterocolitis (NEC) in the low-birth weight infant is now one of the most common surgical problems encountered in contemporary neonatal intensive care units. However, morbidity and mortality from NEC remain high, and the optimal surgical management of these infants remains controversial. Currently few data exist comparing the factors influencing outcome in very low-birth weight infants with perforated NEC treated by either local drainage or exploration. We hypothesize that survival of very low-birth weight neonates with perforated NEC may be more dependent on clinical status than on treatment modality. We present our experience treating a large cohort of infants weighing less than 1000 g with perforated NEC. A retrospective cohort study describes our experience with perforated NEC in very low-birth weight infants in a Level III neonatal intensive care unit. Between January 1991 and May 1998 a total of 70 newbo infants weighing less than 1000 g were evaluated and managed for perforated NEC. Comorbid factors were identified and calculated for each infant. Primary treatment was either local drainage or laparotomy. Statistical analysis was performed by Student's t test and multiple logistic regression. A multiple logistic regression model examined factors (comorbidities, number of comorbidities, and mode intervention) influencing outcome. A Kaplan-Meier survival analysis comparing survival versus number of comorbidities was performed. Twenty-two infants with an average weight of 679 g were treated by local drainage. Forty-eight infants with an average weight of 756 g were treated with exploratory laparotomy. Infants treated by local drainage had a higher cumulative number of comorbid factors (5.2+/-0.50 vs 3.7+/-0.29; P < 0.05) than those managed by operative exploration. Fourteen infants (63%) initially undergoing local drainage for perforated NEC survived. Of the 48 infants 36 operated on survived (75%). No single factor or combination of any comorbid factors was predictive of outcome. The total number of comorbidities for each neonate did reach statistical significance (P < 0.05). A greater likelihood of death was associated with a higher number of comorbidities. Survival with four or fewer comorbidities was 84 per cent, whereas survival with greater than six comorbidities was 30 per cent. The mean number of comorbidities was greater for drainage than for surgery, and for the same number of comorbidities the probability of survival tended to be greater for those treated with drainage than for those undergoing surgery. Multiple logistic regression analysis identified the total number of comorbidities as affecting outcome rather than treatment choice. This suggests therefore that selection of therapeutic options for the patient requires evaluating all factors that may impact survival rather than applying a single treatment strategy for all patients.

Comorbidity↗
PubMedDate not supplied

The features of perforated peptic ulcers in conventional computed tomography.

BACKGROUND/AIMS: CT is not usually of priority to evaluate the pathology of the gastrointestinal tract, especially perforated peptic ulcer. However CT might be employed when the presentation is atypical. The study was to summarize the imaging features of perforated peptic ulcer in conventional CT and assess its ability of detecting perforated peptic ulcer. METHODOLOGY: The CTs of 14 consecutive patients with perforated peptic ulcer confirmed by operation were retrospectively reviewed. The CTs were obtained after intravenous contrast medium, but oral contrast medium was administered only in 5 patients. The CT findings were correlated with surgical findings. RESULTS: Among these 14 patients, all the 14 patients (100%) had extraluminal air accumulation, 10 patients (71%) had abnormal fluid accumulation, and 5 (36%) patients had inflammatory changes in surrounding soft tissues. In addition, conventional CT could only demonstrate the site of perforation in 5 patients (36%) of them. CONCLUSIONS: Conventional CT was valuable in the diagnosis of perforated peptic ulcer, and pneumoperitoneum was the most common feature. However the ability of conventional CT in localizing the site of perforation was poor.

Adult↗
PubMed2002

Non-steroidal anti-inflammatory drugs and perforated diverticular disease: a case-control study.

Non-steroidal anti-inflammatory drugs (NSAIDs) have a wide range of side-effects in the gastrointestinal tract and the large intestine. This study examines the hypothesis that the use of NSAIDs is associated with colonic perforation in diverticular disease. Histological evidence was used to confirm perforation. A retrospective review of case records and pathology reports identified 20 patients admitted over 3 consecutive years. A total of 125 age- and sex-matched patients diagnosed with diverticular disease not complicated by perforation formed the control group. The incidences of NSAID use in the two groups were compared. A second control group consisted of 600 age- and sex-matched randomly selected patients with no known diverticular disease admitted as emergencies in the same period. Of the 20 patients with perforation, 9 were taking NSAIDs for 4 weeks or longer, compared with 19 (15%) of the 125 patients who did not have perforation (relative risk 2.961, 95% confidence interval 1.507-5.348, P < 0.01). 19% of all patients with diverticular disease were taking NSAIDs compared with 10% of the second control group (relative risk 1.869, 95% confidence interval 1.237-2.781, P < 0.01). The findings indicate a strong association between the use of NSAIDs and the perforation of colonic diverticula. The majority of the indications for the use of NSAIDs were cardiovascular and musculoskeletal conditions. Prescribing NSAIDs to patients with diverticular disease carries an increased risk of colonic perforation.

Aged↗
PubMedDate not supplied

[Esophageal perforation caused by balloon dilatations in a patient with achalasia].

OBJECTIVE: To present a case of esophagic perforation due to a pneumatic dilatations of the cardias in a patient with achalasia. BACKGROUND: Achalasia of the esophagus is a primary motor alteration with an unknown cause. The principal characteristics are the lower or absent peristaltic waves in the esophagic body and the impared lower esophagic sphincter relaxation during deglution. The management is palliative with pneumatic dilatations, pharmacologic therapy or with surgery. When a esophagic perforation occurs, it must be diagnosed and treated as soon as possible because a delay in diagnosis and management affect directly the patient prognosis. METHOD: To present a case of esophagic perforation due to pneumatic dilatations of the cardias in a patient with achalasia. CONCLUSIONS: An useful palliative management for achalasia is the pneumatic forceful dilatation, however it carries some risk of perforation; in every patient who was treated with dilatations is mandatory to think in perforation when the clinical condition is different after the procedure. The success of surgical management of the perforated esophagus and the control of sepsis and mediastinitis depends directly of the clinical condition of the patient and the time within perforation and surgical therapy.

Aged↗
PubMed2002

A hole in the drum. An overview of tympanic membrane perforations.

BACKGROUND: Tympanic membrane perforations are common and can be categorised into either acute or chronic. Acute perforations are usually traumatic or inflammatory in origin and heal spontaneously. Chronic perforations may be associated with underlying progressive disease. OBJECTIVE: To differentiate between safe and unsafe perforations and describe management principles for these conditions. DISCUSSION: The majority of acute tympanic membrane perforations heal spontaneously. Those that do not can be considered for surgical repair. Chronic perforations should be viewed as either safe or unsafe depending on the risk of progression to significant complications. Unsafe perforations are often associated with cholesteatoma (an epidermoid cyst of the middle ear and mastoid air cell system). Cholesteatoma destroys bone and causes serious ear and intracranial complications--surgery is commonly required.

Anti-Infective Agents, Local↗
PubMed1976

Perforated peptic ulcer long-term follow-up.

A series of 349 survivors of perforated peptic ulcer was followed for periods of up to 23 years. Almost nine out of every 10 patients suffered from dyspepsia during follow-up. Subsequent elective gastroduodenal surgery was required in more than a quarter of the cases. The surgery rate for gastric ulcer was more than one and a half times that for pyloroduodenal ulcer, and for females almost double that for males. The highest rate of all was for females with gastric ulcer, of whom almost one half came for surgery. One in five patients bled during follow-up. One in eight developed stenosis of the stomach of duodenum, and one in 11 perforated again. There was a significantly increased incidence of subsequent perforation and stenosis in those with an initial perforation of 5 mm or more in diameter. Gastric carcinoma occurred in less than 2% of cases and was restricted to cases of pyloroduodenal perforation. When complications occurred, the majority did so within five years. Only 15% of the 262 patients about whom complete information was available had no complications on follow-up. The indications for definitive surgery at perforation should be extended to include perforated gastric ulcer in the female, particularly if the ulcer is large.

Adolescent↗
PubMed2003

Spontaneous intestinal perforation in a full-term infant: association with infection.

The term spontaneous intestinal perforation suggests a perforation in the gastrointestinal tract of a newborn of no demonstrable cause. Only a few cases have been described in full-term newborns. The aetiology and pathogenesis of the disease are unknown although multiple theories have been proposed. Some authors suggest ischemia as the most likely cause. Conditions associated with fetal or neonatal hypoxia are important antecedents for this emerging distinct entity. We present a case of a spontaneous, intestinal perforation in a full-term neonate with urinary tract infection. There was no clinical evidence of necrotizing enterocolitis or bowel obstruction. Radiological images revealed a pneumoperitoneum. An emergency explorative laparotomy was performed. A localized linear perforation was identified in the transverse colon. Pathological examination of the resected specimens failed to reveal any etiology for the perforation. The neonate recovered rapidly, with no gastrointestinal complications. In our case none of the factors which have previously been associated with intestinal perforation could be implicated. We suggest that focal intestinal perforation is possibly the result of infection. Further studies, including careful recording of cases and close histopathological examination of resected specimens, are required in order to provide more information and improve our understanding of the aetiology of this rare occurance.

Enterococcus faecalis↗
PubMed1962

Perforated peptic ulcer, selective gastric resection in emergency treatment.

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death. In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50. From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage. During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included. In this series also the mortality increased steeply from age 50 onward. Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture. The mortality of perforated ulcers in females was higher than in males. Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.

Aged↗
PubMedDate not supplied

Surgery for perforated peptic ulcer in the elderly. Evaluation of factors influencing prognosis.

BACKGROUND/AIMS: The frequency of perforated peptic ulcer is decreasing among the overall population but it is becoming more frequent among old people. The higher mortality rate in the old population, justifies the search of prognostic factors specific for the elderly. Aim of this study is to analyze and define factors influencing surgical prognosis in patients older than 70 years who were operated for perforated peptic ulcer. METHODOLOGY: A retrospective analysis of 37 patients was performed: age, sex, ASA status, site of perforation, diameter of perforation, duration of symptoms, MPI score, surgical treatment (suture vs. resection) were studied. All patients were grouped as deceased and not deceased after surgery: a statistical univariate analysis was performed regarding the whole series and regarding the patients 70 years and older. RESULTS: Postoperative mortality rate was 18.92% in the whole series but 41.8% among the elderly. In the whole series age, ASA status, diameter of perforation, duration of symptoms, and MPI score were significantly related to postoperative death. In the patients 70 years and older the duration of symptoms, the size of perforation and the MPI score were significantly related to postoperative death. CONCLUSIONS: The duration of symptoms is a known factor that influences the prognosis after surgery for perforated peptic ulcer. This factor is still the most important in the elderly being responsible of the high mortality rate. The delay in treatment is due to a delayed hospitalization of old patients, who show a low reactivity to the disease.

Adult↗
PubMed1992

Management of barium enema-induced colorectal perforation.

Unless recognized and treated promptly, colorectal perforation induced by barium enema examination is a life-threatening complication. Between 1977 and 1986, 13,000 barium enemas were performed at the Mayo Medical Center. Colorectal perforation occurred in five patients (overall incidence: 0.04%). The two colonic perforations were managed by immediate celiotomy with resection in one and primary repair in the other. The three rectal perforations were managed conservatively in two patients and by proximal diversion in one. All patients recovered. Perforations were believed to be related to the tip of the enema catheter or presumably to excessive hydrostatic pressure. In contrast to other reports, barium enema-induced colorectal perforation is not always fatal when recognized early and treated aggressively. Localized, contained extraperitoneal rectal perforation may be managed conservatively in selected patients.

Aged↗