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PubMed1984

Nontraumatic perforation of the small intestine.

Nontraumatic perforation of the small intestine is very rare in western countries, while typhoid fever is the most common cause of such perforation in other parts of the world. A series spanning 24 years is reviewed, comprising 112 adults with perforation of the small intestine resulting in peritonitis. Perforations due to Crohn's disease, strangulation, postoperative complications and malignancy are not included. Causes of perforation were ingested foreign body (24 cases), radiotherapy (18), potassium chloride medication (13), diverticula of the small bowel (10), Zollinger-Ellison syndrome (2), and tuberculosis, actinomycosis and intrauterine contraceptive device (each in 1 case). The etiology could only be suspected in 13 cases and in 31 it was unknown. Difficulties in making the preoperative diagnosis contributed to lateness of surgical intervention. Mortality (23%) was related to patient age and cause of the perforation. The series permitted no conclusions concerning relationship between surgical method and mortality rate, but it is recommended that the method be adapted from case to case, depending on the etiology of the perforation.

Adult↗
PubMed1982

Management of instrumental perforations of the esophagus.

Experience with 47 consecutive instrumental perforations of the esophagus is described. Perforation occurred in the cervical esophagus in 18 patients, mid-thoracic esophagus in 12, and distal esophagus in 17. The majority of patients (87%) harbored a primary esophageal disorder necessitating esophageal instrumentation. Eight select patients were treated nonoperatively with one death; however, some form of morbidity with prolonged hospital stay occurred in half of these patients. In contrast, 39 patients underwent emergency surgical intervention. Only one death occurred in the 31 patients treated by local drainage and attempted closure of the perforation. However, three of six patients with distal perforations treated by esophageal resection with primary esophagogastrostomy died in the early postoperative period. Our results suggest that most instrumental perforations of the esophagus should be managed surgically. Drainage and closure of cervical perforations yields goods results. Esophageal resection with primary reconstitution of esophagogastric continuity should be reserved for select situations. Nonoperative management might be entertained in minimally symptomatic patients harboring a late, locally contained perforation without signs of ongoing sepsis.

Adolescent↗
PubMedDate not supplied

Typhoid perforation: factors affecting mortality and morbidity.

Thirty-six patients were operated upon for terminal ileal perforations in a two-year period; four cases were due to trauma, four to ascariasis and 28 to typhoid. Ileal perforations due to ascaris worms are differentiated from typhoid ileal perforations because worms are usually found lying freely in the peritoneal cavity or in close association with the perforations. Also, tests for Salmonellae and Shigella are usually negative. Factors affecting mortality and morbidity in typhoid ileal perforation include the age of the patient, duration of perforation before surgery, presence of additional complications, such as massive rectal bleeding, the extent of the surgery, and the number of perforations present. Chloramphenicol in massive doses is indicated for all these patients. Our experience suggests that the hematoxicity of this drug has been over-rated. Postoperative complications are: wound infection (about 95% of cases), malarial fever, septicemia, fecal fistula, intraabdominal abscess, pulmonary infection, jaundice and transient psychosis.

Adolescent↗
PubMed1981

[Abdominal complications of V-P or L-P shunt operation --a bowel perforation and historical review (author's transl)].

We have experienced a case of shunt tube perforation into the transverse colon in which a Pudenz infantile V-A shunt tube was installed for a hydrocephalic baby. The shunt operation was performed at a year and one month of his age in this patient and bowel perforation was disclosed and corrected twenty months following the operation. From a retrospective point of view, however, slight sign of meningitis could be suspected two months earlier and judging from his symptoms of transient intracranial hypertension, the bowel perforation might be traced back even earlier. In the past twenty year history of V-P shunt maneuver, quite a number of papers on various kinds of specific complications have been reported. On reviewing these reported cases out of English and Japanese literature, numerous abdominal complications such as twenty-eight perforations, fifty CSF ascites or pseudocysts, three umbilical perforations, two vaginal perforations, five migrations into scrotum, and some volvulus and bladder perforations can be collected. These are summarized and discussed briefly in this paper.

Ascites↗
PubMed1995

Uterine perforation during elective first trimester abortions: a 13-year review.

OBJECTIVE: The purpose of this study was to determine the incidence, presentation, management and outcome of uterine perforation during elective first trimester abortions. METHODS: We conducted a retrospective study of 40 patients, including 2 transferred patients, who sustained uterine perforation during elective abortions from January 1980 to December 1992. RESULTS: The incidence of uterine perforation was 0.8 per 1,000 procedures (0.08%). There were 8 (20%) nulliparae and 3 (7.5%) grand multigravidae. 82.5% of the cases occurred when the abortion was performed by medical officers or junior registrars under training. The commonest perforating instrument was the suction cannula (25%) followed by the uterine sound (22.5%) and the dilator (20%). Three (7.5%) cases were treated conservatively, 33 (82.5%) cases underwent emergency operation, 2 (5%) cases were discovered during subsequent sterilisation, and 2 (5%) cases suffered undiagnosed perforation and were re-admitted for emergency surgery. Morbidity included post operative fever (12.5%), bowel injury (7.5%), retained conceptus (5%) and wound breakdown (2.5%). There was no mortality. CONCLUSION: A careful assessment of the uterine size and position, vigilance in the use of uterine sound and dilators, greater care in the use of suction cannula, and experience in vacuum aspiration will decrease the incidence of uterine perforation during elective abortions. A high degree of suspicion, early diagnosis and treatment will prevent the potential complications that may arise from uterine perforation.

Abortion, Induced↗
PubMed1993

[Omental implantation technique for esophageal perforations--a clinical case and experimental studies].

We successfully used the omental implantation technique in a case of esophageal perforation in which simple closure was impossible because of extreme inflammatory changes. Although excellent results have been obtained by this method in gastroduodenal perforations, it has never been used before in cases of esophageal perforations. In this study we subsequently investigated the histological repair mechanism by carrying out animal experiments. Clinical case A 59-year-old male entered our hospital with the symptoms of chest pain and fever after endoscopic therapy for esophageal obstruction by food impaction. He underwent an emergency thoracotomy 54 hours after endoscopy. A perforation of about 2 cm in diameter was observed in the subthoracic esophageal wall which become too weak to close by stitching. This perforation was filled with an omental plug inserted from the peritoneal cavity under laparotomy. The patient recovered and his perforated lesion was completely repaired. Animal experiment In 10 hybrid adult dogs, omental implantation was performed on perforations of more than 1 cm in diameter in the subthoracic esophagus made by electric coagulation. One to four weeks postoperatively, these inserted omentums were observed endoscopically before sacrifice. The implanted omentums were endoscopically observed as elevated lesions after 2 weeks, but they became flat after 3 weeks and the mucosa seemed to be almost normal after 4 weeks. Histological investigation showed that the implanted omentums maintained their original structure accompanied by remarkable inflammatory changes 1 week postoperatively.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1993

Perforated gastric and duodenal ulcer: an analysis of prognostic factors.

A review of patients treated operatively for perforated ulcer was undertaken to determine factors that independently predict mortality and morbidity. From 1980 to 1989 84 patients were treated with operative mortality and morbidity rates of 18 and 37 per cent, respectively. Patients with gastric ulcer were significantly older and were more likely to have concomitant medical problems, to use steroids, and be hospitalized at time of their perforation. They also had a higher perioperative mortality rate when compared to patients with gastroduodenal ulcers (P < 0.05 for each). Patients treated with definitive operation (n = 51) had a significantly lower recurrent ulcer rate when compared to an equivalent group treated with simple closure (n = 33) (mean follow-up, 47 months). Multivariate analysis confirmed a patient's likelihood of complication or death could be predicted using three variables (P < 0.03); age greater than 42 years, hospitalization at time of perforation, concomitant medical illness. While the relative distribution of these three factors in patients with gastric versus peptic ulcers appears to account for the difference in outcome between these two groups, the distribution of these factors between patients treated with patch closure and definitive operation was not significantly different. Patient outcome from operation for perforated ulcer is dependent on preoperative conditions and appears to be independent of surgical procedure performed. There was no benefit to simple closure of a perforated ulcer. Definitive procedures of perforated ulcers are associated with lower ulcer recurrence and therefore are advocated to treat perforation.

Adolescent↗
PubMedDate not supplied

[Perforation in Crohn's ileitis and its impact on the natural history of the disease. Note 1. Pathogenic process of the event, its relationship with intestinal obstruction, and its immediate consequences].

The pathogenesis and consequences of perforation in Crohn's disease were studied in 175 patients submitted to surgery. Perforation occurred in 40 (23%) patients with ileitis or ileocolitis, always in the terminal ileum; so-called "free" perforation occurred in 1 patient, "limited" perforation in all the others. Perforation is always a consequence of a chronic intestinal obstruction caused by the stricture of the terminal ileum, which becomes absolute because of the blocking by solid intestinal content. It occurs in the borderline between the stricture and proximal dilated loop, where the fissures (typical of Crohn's ileitis) are stretched to the utmost and dilated by the hyperpressure and distension of the wall following ileal stenosis. Perforation in the peritoneal cavity is always free; its consequence is usually not a diffuse septic peritonitis but an abscess, because only a small amount of intestinal content leaks out. This happens because in the proximal occluded bowel, pressure decreases abruptly following the spilling of intestinal content, particularly of gas. The abscess fed by intestinal content enlarges and finally opens into a hollow organ or onto the skin, causing a fistula (internal or external). The rational therapeutic approach to perforation and its consequences (the infrequent diffuse septic peritonitis, or the more common abscesses and fistulas) is always and only ileal stenosis removal.

Crohn Disease↗
PubMed1996

[Non-surgical treatment of perforations of the thoracic esophagus].

OBJECTIVES: Thoracic oesophageal perforations are life-threatening conditions requiring immediate treatment. The type of treatment remains however controversial. The aim of this study was to evaluate the efficacy of the nonoperative management in this disease. METHODS: Six patients were admitted in our surgical unit for thoracic oesophageal perforations during the study period. One perforation was spontaneous (Boerhaave's syndrome). One had complicated an oesophageal ulcer. Two were secondary to caustic lesions. Two were secondary to instrumental dilations. The diagnostic and therapeutic delay was < or = 1 day in 5 cases. In one case the delay was 4 days but the mediastinitis was well tolerated. The treatment was based on antibiotics, nasoesophageal tube suction, and total parenteral nutrition. RESULTS: There was no death in this group of patients. The mediastinitis healed in all cases. In the follow-up period two patients did not have nutritional restriction after healing. Three patients complained of oesophageal stenosis which required oesophageal replacement (n = 2) and dilation (n = 1). One neoplastic stenosis required an endoprosthesis. CONCLUSION: Nonoperative treatment is feasible and safe in selected cases of thoracic oesophageal perforations: perforations diagnosed early and confined to the mediastinum, instrumental perforations, and perforations diagnosed late but well tolerated.

Adult↗
PubMed1995

[Colonic perforations complicating colonoscopy. Apropos of 15 consecutive cases observed over 16 years].

OBJECTIVES: Our study was undertaken to better assess the circumstances of perforation during colonoscopy. METHODS: All cases observed in our department between 1978 and 1994 were computer recorded. During this period, 5,822 colonoscopies were performed, including 872 with at least one polypectomy. RESULTS: All perforations occurred during colonoscopies performed under anaesthesia (n = 3,373 vs 2,449 without anaesthesia). There were a total of 15 observations of colonic perforations, 1 perforation in 388 colonoscopies. Ten perforations occurred during diagnostic colonoscopies (0.20%), 5 after polypectomy (0.57%). Eight of 10 perforations complicating diagnostic colonoscopies occurred below an impassable stricture. Two patients died from this complication (0.03% of all colonoscopies). CONCLUSIONS: Our study suggests that endoscopic exploration of colonic stricture, in addition to anaesthesia, increases the risk of colonic perforation.

Aged↗
PubMedDate not supplied

The effect of H. pylori in perforation of duodenal ulcer.

BACKGROUND/AIMS: H. pylori has been described as an opportunistic pathogen attracted by changes in the gastric mucosa caused by inflammation and ulceration. However, the role of H. pylori infection in the perforation of duodenal ulcers has not yet been clearly determined. The aim of this study was to assess the prevalence of H. pylori infection in patients undergoing laparotomy for repair of a perforated duodenal ulcer. METHODOLOGY: Patients who underwent surgery for a perforated duodenal ulcer in our Surgical Unit between January 1994 and July 1996 were included in this study. The study population consisted of eighteen patients with a mean age of 32.7 (21-48) years. All of the patients were male. Patients with chronic duodenal ulcer perforation and with no contraindications for definitive surgery, such as peritonitis, shock (blood pressure <90 mm Hg), age >60 years, or more than a 12-hour elapse from the time of perforation, were treated by bilateral truncal vagotomy and Weinberg pyloroplasty. The ulcer was excised with the pyloric ring. The cut was then extented by about 2 cm on both the gastric and duodenal sides. Two biopsies were taken from the antral mucosa by endoscopic biopsy forceps. The defect was closed transversely. The ulcer specimen and the antral biopsies were fixed separately in 10% formalin solution and sent to the department of Histopathology. The specimens were stained with Hematoxylin-Eosin and examined for H. pylori . Sections of the ulcer specimen were especially investigated for the presence of H. pylori through all layers of the ulcer. RESULTS: H. pylori was found in the antral biopsies of 16 patients (88.8%). In seven of the ulcer specimens (38.8%), H. pylori was present in the mucosa and also extended through the wall of the ulcer. H. pylori was positive in the antral biopsies of all patients with H. pylori present in the ulcer wall. CONCLUSIONS: In our study, H. pylori was present at a high ratio in the antral biopsies of patients with duodenal ulcer perforation. The presence of H. pylori throughout the ulcer wall to a considerable extent emphasizes the fact that eradication of H. pylori is important in the treatment of perforated duodenal ulcer.

Adult↗
PubMed1990

Results of penetrating keratoplasty for the treatment of corneal perforations.

We retrospectively analyzed 46 consecutive cases of penetrating keratoplasty performed as part of the treatment of corneal perforations; the minimum follow-up time after keratoplasty was 7 months. Predisposing conditions leading to perforation were an infectious keratitis in 26 eyes (57%), trauma in 14 eyes (30%), and corneal melt associated with ocular surface disorder in 6 eyes (13%). The success of penetrating keratoplasty in the treatment of corneal perforation depended on the timing of surgery and the cause of the perforation. If the perforation was traumatic in origin, delaying surgery for at least 3 months significantly improved the chances for graft success. Eighty percent of the penetrating keratoplasties delayed 3 months following primary repair of corneal laceration remained clear, and 50% of these patients had a visual acuity of 20/60 or better. If penetrating keratoplasties were performed for an infectious corneal perforation, grafts had a better chance to remain clear if surgery could be delayed. All grafts performed for corneal perforation associated with melting and ocular surface abnormalities failed.

Adolescent↗
PubMed1993

Unsuspected glove perforation during ophthalmic surgery.

OBJECTIVES: To determine the rate of perforation of surgical gloves after ophthalmic surgery and to identify factors that contribute to the development of perforations. DESIGN: Case-control study of used and unused surgical gloves collected during a 7-month period. SETTING: The ophthalmology surgical suites of a major teaching hospital. MAIN OUTCOME MEASURES: Development of glove perforations as measured by five different techniques. RESULTS: We tested 103 pairs of latex surgical gloves before use and 454 pairs of gloves after use. Of five techniques used to test for pinholes, air inflation with water submersion and compression was found to be the most sensitive, yielding a 6.80% prevalence in control glove pairs and a 21.81% prevalence in study glove pairs (P = .0005). When examined by subspecialty area, the lowest perforation rate (11.39%; P = .00009) occurred in cataract and intraocular lens surgery and the highest rate (41.67%; P = .003) occurred in oculoplastic surgery. Factors that correlated significantly with the development of perforations as determined by multiple logistic regression analysis included pediatric ophthalmology and strabismus surgeries, oculoplastic surgeries, level of training of the surgeon, duration of operation, and larger glove size. The thumb and index fingers of the nondominant hand contained the largest numbers of pinholes. CONCLUSIONS: The rate of surgical glove perforation after ophthalmic surgery is relatively high. Recommendations for reducing the rate of glove perforation are discussed.

Case-Control Studies↗
PubMed2004

Nontraumatic perforation of the bile duct in adults.

HYPOTHESIS: Nontraumatic perforation of the bile duct in adults is rare, and the management of this condition should resolve the primary pathologic lesion. DESIGN: Retrospective analysis of 11 patients who were diagnosed as having nontraumatic perforation of the bile duct. SETTING: A public university medical center and a private university medical center. PATIENTS: Five men and 6 women (median age, 64 years) with nontraumatic perforation of the bile duct were treated between September 1993 and May 2003. INTERVENTIONS: Two patients with common bile duct (CBD) stones, who were initially diagnosed as having mediastinal abscess and subcapsular biloma, respectively, were treated by nonoperative management, ie, endoscopic sphincterotomy and percutaneous abscess drainage. The remaining 9 patients were treated surgically, which included an exploration of the CBD, placement of a T tube, and a liver resection. MAIN OUTCOME MEASURES: Initial manifestation, primary disease, perforation site, management, surgical morbidity, and mortality. RESULTS: All patients had acute abdominal pain, which was caused by intraabdominal abscess in 7 patients, diffuse bile peritonitis in 3, and subcapsular biloma in 1. Their primary diseases were CBD stones in 7 patients, intrahepatic duct stone in 2, a choledochal cyst in 1, and phytobezoar with food stuff in the CBD in 1. Perforations occurred at the left intrahepatic duct in 9 patients, the CBD in 1, and the cyst wall in 1. All patients recovered, except 1 patient who expired owing to multiorgan failure because the operation could not be performed in time. CONCLUSIONS: Nontraumatic perforation of the bile duct should be suspected if perihepatic abscess or peritonitis is combined with biliary stone disease. The management of nontraumatic perforation of the bile duct should include the eradication of the primary pathologic lesion and the control of abscess or peritonitis.

Adult↗
PubMed2005

Effect of laser perforation on the remodeling of acellular matrix grafts.

Autologous cells migrate only slightly into acellular matrix grafts. This study was carried out in small-diameter, allogeneic matrix grafts to investigate the effects on cell repopulation and remodeling caused by increased wall porosity induced by laser perforation. Allogeneic ovine carotid arteries were decellularized by dye-mediated photooxidation (Photofix). Matrix grafts (10 cm x 4 mm i.d.) were perforated with holes of 50 microm diameter at a density of 50 holes/cm(2) using a Ti-sapphire laser. The grafts were implanted in the carotid arteries of 10 sheep and were compared to nonperforated grafts implanted contralaterally. The prostheses were retrieved after 6 weeks or 3 or 6 months following implantation and were evaluated by histologic examination, immunohistochemical staining, and scanning electron microscopy. All grafts, except one of the perforated specimens, remained patent. Perforated implants, examined at 6 weeks, showed faster recellularization with endothelial cells than did the corresponding contralateral controls. Perforated grafts, examined at 6 months, showed a significantly thicker neointima and clear signs of neovascularization: endothelial cells, basal lamina, elastic fibers, circular and longitudinally orientated smooth muscle cells in comparison to nonperforated specimens. Repopulation of the decellularized matrix with host cells was higher in the perforated than in the nonperforated prostheses. These results suggest that the increased matrix porosity induced by laser perforation promotes graft remodeling and reconstitution with host cells.

Animals↗
PubMed1992

Perforated synapses are present during synaptogenesis in rat neocortex.

It has been known for some time that perforated synapses increase in number and size with increasing age. Initially, these trends were used to support the concept that nonperforated synapses enlarge until an optimal size is reached, at which point they perforate and may subsequently split. More recent stereological and three-dimensional reconstruction investigations, however, suggest that this may not be the case and that perforated and nonperforated synapses constitute separate synaptic populations. In order to test the separate population hypothesis, synapses have been studied ultrastructurally in the parietal cortex of rats aged 19 and 20 days gestation, and 1 and 4 days postnatal. By examining synapses serially, and also by studying three-dimensional reconstructions, it has been demonstrated that perforated synapses are present at each of these ages. Some are relatively simple in organization, resembling previously described perforated synapses at 14 days of age, although others appear to consist of two or more separate PSD components. These findings demonstrate that perforated synapses are present from early on in synaptogenesis and that developing perforated synapses may have distinct characteristics that cast light on their developmental course.

Animals↗
PubMed1991

A comparison of hyaluronan and fibronectin in the healing of tympanic membrane perforations.

Fibronectin and 1% hyaluronan, two extracellular matrix components, were applied to tympanic membrane (TM) perforations, using the laboratory rat as an animal model. The perforations occupied the upper, posterior quadrant of the TM. Saline-treated and untreated perforations of equal size served as controls. Fifty percent of the perforations treated daily with hyaluronan healed prior to the first closures of the other groups. The use of fibronectin did not enhance the healing rate. The hyaluronan-treated perforations were covered initially by a sheet of keratin and hyaluronan containing abundant inflammatory cells. Within this keratin-hyaluronan cover, hyperplastic stratified keratinizing epithelium advanced and bridged the gap of the perforation ahead of the approaching connective tissue. These findings indicate that exogenously applied hyaluronan could be valuable in the clinical situation and should be tried to improve the healing of TM perforations.

Animals↗
PubMed1996

Subfascial endoscopic perforator vein surgery: a preliminary report.

Although the open Linton subfascial perforator vein interruption operation succeeded, for the most part, in preventing recurrent venous ulceration, it was associated with morbidity and prolonged hospitalization. We have attempted to obtain the beneficial effects of perforator interruption by the less invasive procedure of subfascial endoscopic perforator vein surgery using laparoscopic instrumentation and limited or no hospitalization. A total of 31 consecutive operations were performed in 30 patients. Sixteen women and 14 men were entered into the study, and all of them had severe chronic venous insufficiency with either open or healed ulcers. Operations were carried out without gas insufflation, in 17 without a hemostatic tourniquet, and in 13 entirely on an outpatient basis. The 18 hospitalizations produced a total of 49 days of inpatient care (mean 2.72 days). One to six perforating veins were encountered in these operations, and veins identified as perforators were electrocoagulated or clipped and sectioned. Sixteen limbs had severe chronic venous insufficiency or healed ulcers, and 15 had open ulcers. In 13 limbs, ulcers were intermittently present for 1 to 5 years. Seven of these healed within 4 weeks of operation and four others within 8 weeks. Two healed more than 8 weeks after surgery. In two limbs with ulcers that were present for 1 to 6 months, healing took place within 4 weeks of the operation in both. Complications included atelectasis in one patient, cellulitis requiring antibiotic therapy in three, wound hematomas not requiring intervention in two, and wound seroma not requiring therapy in one. This preliminary experience suggests that perforator vein interruption can be accomplished using existing instrumentation and a variety of technical modifications to achieve the objectives of the Linton operation without the attendant morbidity. Videoscopic instrumentation obtains benefits of subfascial perforator vein interruption without morbidity of the open operations. This preliminary study suggests that the operative procedure is attended by minimum morbidity without the need for rehospitalization. Long-term observation will be required to assess the procedure definitively, but the short-term objectives can be safely accomplished with minimum use of inpatient facilities.

Ambulatory Surgical Procedures↗