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PubMed2000

Radio frequency perforation of cardiac tissue: modelling and experimental results.

Radio frequency (RF) current delivered through a thin catheter can be used to perforate the pulmonary valve or the atrial septum to treat pulmonary atresia in newborns. To understand better the mechanisms of RF perforation, a numerical model is developed, and experiments are performed in isolated canine cardiac tissue. The model consists of a cylindrical domain with a tissue layer between two blood layers. The finite-difference method is used to compute both the potential and temperature distributions. When the tissue temperature exceeds 100 degrees C in all points that are directly in front of the catheter, these points are considered to be instantly vaporised, and the catheter advances over these points. The computed temperature time course coincides with measured temperature at small voltages (< 16 V). Simulated perforation occurs when the voltage exceeds a threshold of 70-80 V for a catheter diameter of 0.30-0.44 mm, which coincides with experimental observations in the myocardium. A voltage exceeding this perforation threshold tends to decrease tissue damage. Shorter electrodes (0.7 mm as against 2.4 mm) with smaller diameters produce a more rapid perforation. In conclusion, numerical simulations provide insights into aspects of RF perforation, such as electrode size, current, speed of perforation and collateral damage.

Animals↗
PubMed2004

Acute and long-term outcome after coronary artery perforation during percutaneous coronary interventions.

BACKGROUND: Coronary artery perforation is a rare but serious complication of percutaneous coronary interventions (PCI). METHODS: We reviewed our database for cases of overt coronary perforation during PCI procedures. Hospital charts, procedural reports, and coronary angiograms of these patients were reviewed, with particular emphasis on mechanisms of perforation, management of the complication, and clinical outcome. RESULTS: Between 01/1998 and 12/2003, a total of 19 cases (mean age: 66+/-8 years, 13 male) of coronary perforation occurred during 6433 PCI procedures performed within this period (incidence: 0.3%). In 12/19 (63%) cases, perforation occurred during recanalisation procedures of chronic total occlusions of coronary arteries. In all but one patient, non-surgical management was attempted: 2 out of 19 (11%) patients were treated conservatively by reversal of heparin anticoagulation. Prolonged balloon inflation at the perforation site was applied in 10/19 (53%) patients. Six (32%) patients received stents (5 of them received covered stentgrafts), 3 (16%) patients developed cardiac tamponade requiring percardiocentesis, and only 2 (11%) patients underwent bailout surgical repair. There were 2 (11%) deaths early after the procedure. CONCLUSION: Coronary perforation during PCI is a rare complication, but is associated with significant morbidity and mortality. In the majority of patients, non-surgical management is both feasible and associated with a high success-rate.

Aged↗
PubMed2002

Frequency of glove perforation and the protective effect of double gloves in gynecological surgery.

The purposes of this prospective study were to verify the frequency of glove perforation during gynecological operations and to evaluate the efficacy of double gloving in preventing damage to the inner glove. From May 2000 to May 2001, three house staff and 12 residents were asked to place their used gloves in bags labeled with the following information: procedure performed, presence of a recognized glove perforation, and role in operating team (surgeon, first or second assistant, and instrumentalist). All glove sets were tested using the method of water pression. Damaged gloves were excluded from that analysis. In all, 35 and 51 operations were utilized with single and double gloves, respectively. There were 240 single gloves and 792 double gloves tested. Perforation occurred in 10.4% of the single gloves and 9.8% of the outer double gloves. There were no cases of perforation in the inner double gloves. In cases of operating time that lasted more than 2 h, 56% of the surgeries that used single gloves had perforation vs 58.5% of the double gloves. The first assistant had the major risk for glove perforation with the use of single or double gloves. The indicator finger of the non-dominant hand was the major risk for perforation. In conclusion, we recommend double gloving in all gynecological surgery to reduce the risk of contracting blood-borne diseases.

Equipment Failure↗
PubMed1999

The risk of gallbladder perforation at laparoscopic cholecystectomy.

BACKGROUND: The best policy to prevent the potential hazard of bile and stones spilled at laparoscopic cholecystectomy (LC) is to avoid inadvertent gallbladder (GB) perforations. No study so far has investigated the mechanisms of GB rupture and its predictive risk factors. To address these issues and help define the best strategies to reduce undesirable long-term sequelae, we did a retrospective review of the first 350 consecutive LC performed by a single surgeon at our institution. METHODS: The clinical and surgical records of our first 350 consecutive LC were reviewed. The significant variables identified on univariate analysis were eventually validated through Spearman's correlation for ordered data and finally correlated to the risk of GB perforation by means of a casewise deletion multiple regression. The equation of the linear regression thus obtained was used to predict the probability of GB perforation by number of risk factors. RESULTS: Three risk factors predictive of GB perforation were identified: chronic cholecystitis with thickened walls >7 mm on preoperative ultrasound (US), GB hydrops (GB > 8 x 4 x 4 cm on US), and previous laparotomies. The incidence of GB perforation rose from a low of 3.5% in the absence of any risk factor to a high of 25% for patients with all three of the independent variables. GB hydrops yielded the highest diagnostic accuracy and probability of perforation (OR = 4.9). CONCLUSIONS: Inflammation and a positive history of previous laparotomies play a crucial role in GB perforation at LC. Hydropic GB was the most accurate predictor of rupture. A prospective trial is needed to confirm the data.

Adult↗
PubMed2004

Closed subfascial ligation of incompetent perforating veins of the lower extremities.

The purpose of this study was to determine the effectiveness of minimally invasive surgical procedures for interrupting incompetent perforating veins of the lower limb. A closed subfascial ligation was performed in 20 patients who had incompetent perforating veins in 28 limbs as diagnosed by a clinical examination and duplex scanning. Two small transverse incisions measuring 5-10 mm in length were made on both sides of the incompetent perforating vein. Using an aneurysmal needle, a suture (polypropylene No. 1) was placed in the subfascial plane to encircle the incompetent perforating vein from all directions. Next, this suture was tied through two incisions to ligate this perforator. The mean follow-up period was 26 months. The ligation of the incompetent perforators was successful in 27 of 28 limbs and no wound complications were observed. A closed subfascial ligation of incompetent perforating veins of the lower limbs is thus considered to be easy to perform, not overly invasive, safe, and to also have very encouraging results.

Adult↗
PubMed1990

Increase in the relative proportion of perforated axospinous synapses following hippocampal kindling is specific for the synaptic field of stimulated axons.

A comparative analysis of axospinous synapses was performed in the middle (MML) and inner (IML) molecular layer of the hippocampal dentate gyrus of rats kindled via medial perforant path stimulation and sacrificed 4 weeks after reaching a criterion of 5 generalized seizures. The MML was a directly stimulated structure, while the IML was not. Both are immediately adjacent synaptic fields likely to be equally susceptible to any generalized effects of convulsions and hypoxia. In these two subdivisions of the molecular layer, the so-called perforated and non-perforated synapses, distinguished respectively by a discontinuous or continuous postsynaptic density, were differentially quantified. In the MML, the ratio of perforated to non-perforated synapses was found to be markedly increased in kindled rats relative to controls. In the IML, however, no change in this ratio was detected following kindling. Thus, the shift in the relative preponderance of perforated synapses over non-perforated ones is not a consequence of generalized phenomena accompanying the kindling process.

Animals↗
PubMed1995

Repair of mucosal perforation during pyloromyotomy: surgeon's choice.

Mucosal perforation during Fredet-Ramstedt pyloromyotomy traditionally has been repaired with muscular and mucosal reapproximation, pyloric rotation, and repeat myotomy. The purpose of this study was to determine whether simple mucosal closure is a safe alternative repair technique for such a perforation. The authors reviewed their experience of pyloromyotomies over a 21-year period and found a 1.67% incidence (15 of 896) of mucosal perforation. Four of these patients had repair with rotation and repeat myotomy, and 11 had repair with primary mucosal approximation. The patients were compared with respect to demographics, duration of operation, postoperative feeding intolerance, time from operation until discharge, and postoperative complications. No differences were noted between the two groups. Interestingly, when the perforation group (n = 15) was compared with the nonperforation group (n = 881), the mean age at time of pyloromyotomy was significantly higher for the group with perforation 48 days v 34 days; P = .0021, Student's t test). The authors conclude that those most likely to suffer mucosal perforation during pyloromyotomy are older patients with pyloric stenosis. Such mucosal perforation can be repaired with equal efficacy and safety using the traditional pyloric rotation approach or primary mucosal closure.

Female↗
PubMed1992

The clinicoradiologic predictability of perforations of the soft tissue of the temporomandibular joint.

One hundred thirty-one arthrographic examinations of temporomandibular joints were performed on 119 patients. The relationships between clinical symptoms, tomographic findings, and soft-tissue perforation were examined. Perforations of the articular disk or posterior attachment were revealed in 58 joints. Joints with crepitation showed a high frequency of perforation (20 of 22). Pain in the joint area and limitation of opening correlated to disk reduction. Perforations were observed in 12 of 21 joints with continuous pain. Osseous changes were detected in 89 joints. Joints with abnormal radiodensity (erosion, sclerosis) combined with abnormal shape (pocket erosion, osteophyte formation, deformity) showed a high frequency of perforation (41 of 45), which corresponded to 84% in this study. In those cases with osseous change or crepitation, positive predictive values of perforation were both 91%. These types of osseous change and their clinical significance might predict soft-tissue perforation with high accuracy before an arthrogram is performed.

Adolescent↗
PubMed2006

Treatment of coronary artery perforations complicating percutaneous coronary intervention with a polytetrafluoroethylene-covered stent graft.

Coronary artery perforation is a rare, but dreaded, complication of percutaneous coronary intervention. Conventional treatment, including reversal of anticoagulation and prolonged balloon inflation, is associated with a high incidence of death, Q-wave myocardial infarction, and emergency coronary bypass surgery. Although a number of case reports have demonstrated the feasibility of sealing coronary perforations with synthetic material-covered stent grafts, the efficacy of this treatment has not been reported in a large, multicenter series. We used a retrospective international registry to examine the outcomes of the polytetrafluoroethylene-coated JOSTENT coronary stent graft (CSG) in 41 cases of coronary perforations. Perforations were relatively severe: 16.7% Ellis grade 1, 54.2% grade 2, and 29.1% grade 3. Of the 41 patients, > 1/3 (n = 14) experienced life-threatening complications before stent graft implantation, including pericardial tamponade (12.2%), cardiogenic shock (9.8%), and cardiac arrest (2.4%). A total of 52 CSGs were used to treat the 41 perforations (mean 1.3 per lesion). All CSGs were placed successfully, with 92.9% of the perforations sealed completely and 7.1% partially. One patient developed abrupt vessel closure after CSG deployment, resulting in an overall procedure success rate of 96.4%. No in-hospital Q-wave myocardial infarctions, emergency coronary bypass surgeries, or deaths resulted. The CSG may be a reliable and highly effective treatment option for sealing coronary perforations complicating percutaneous coronary interventions.

Aged↗
PubMed2006

Management and outcomes of coronary artery perforation during percutaneous coronary intervention.

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.

Adult↗
PubMed2004

[Iatrogenic perforation of the gallbladder during laparoscopic cholecystectomy does not influence the prognosis. Prospective study].

BACKGROUND: Perforation of the gallbladder and spillage of gallstones frequently occur in laparoscopic cholecystectomy. As stones may be lost and as spilled bile is known to be contaminated, influence on morbidity may be expected. AIMS: To evaluate the immediate and late consequences on morbidity of peroperative gallbladder perforation during laparoscopic cholecystectomy (LC) in an universitary hospital center. PATIENTS AND METHODS: One hundred and twenty one LC were prospectively evaluated with a mean follow-up of 30 months. Elective operations on 30 men and 91 women with a mean age of 56.4 years (18-85) were carried out for symptomatic cholecystolithiasis in 97 cases (80%), and in 24 cases for complicated cholecystolithiasis. The "french technique" was used for all LC, with systematic intra-operative cholangiography and ultra Sonography. Thirty-seven (30.5%) LC were performed by surgical trainees, 84 LC by confirmed surgeons. The consequences of ultra-operative gallbladder perforation were evaluated in the immediate postoperative period, especially for septic complications, and thereafter, patients were followed up 1, 6, 12 and 24 months postoperatively. RESULTS: Ultra-operative gallbladder perforation occurred in 24 cases (20%), in 83.3% during gallbladder dissection. Gallstone spillage occurred six times, and all spilled stones were removed. Gallbladder perforation was more frequent (but non significant) in acute cholecystitis (25 vs 19%, ns). A clear correlation to the skill and experience of the surgeon is shown (32.4 vs 14.2%, P =0.01). Gallbladder perforation is accompanied by an elevated (nonsignificant) postoperative morbidity (16.6 vs 7.2%, P =0.62) which is, in fact related to older patient and more acute cholecystitis in this group. No reoperations were necessary. One and two years follow-up revealed no long-term complications specially due to lost gallstones. CONCLUSION: Peroperative gallbladder perforation during LC carries no morbidity, provided a total and complete recuperation of gallstones spilled and local treatment of bile contamination with local irrigation and antibiotics. This complication is correlated to the surgeon's skill and experience.

Adolescent↗
PubMed2005

Unnoticed glove perforation during thoracoscopic and open thoracic surgery.

BACKGROUND: Surgeons tend to underestimate the risk of transferring infection during thoracoscopic operations, although data on glove perforation in thoracoscopic operations have not been reported. METHODS: Unnoticed perforations of the gloves worn by the same primary surgeon during thoracoscopic procedures and open thoracotomy were studied. Gloves with gross damage and those changed due to assumed damage were excluded. Gloves were tested by filling with water and squeezing to inflate each finger, which could detect a perforation by a 30-gauge needle. RESULTS: Perforation was found in 25% after thoracoscopic operation, although this was significantly lower than 70% after open thoracotomy. Twelve percent of the gloves worn during thoracoscopic operation were perforated. The perforation rate was higher for gloves worn for more than 2 hours during thoracoscopic operation. CONCLUSIONS: Glove perforation occurred without being noticed in 25% of thoracoscopic procedures, and in 12% of the gloves used during the procedure. Glove change within 2 hours is recommended.

Adolescent↗
PubMed2004

Free thoracodorsal artery perforator flap in extremity reconstruction: 12 cases.

The need for thin flap coverage has increased, especially for contouring or covering shallow defects of extremities. The free thoracodorsal artery perforator flap harvested from the upper lateral back can be useful for this purpose. The thoracodorsal artery supplies the latissimus dorsi muscle and supplies perforating branches to the overlying skin. The flap is based upon the proximal perforator of the thoracodorsal artery, which usually emerges in an area approximately 8-10 cm below the posterior axillary fold and 2-3 cm posterior to the lateral border of the latissimus dorsi muscle. Between February of 2001 and April of 2003, we used the free thoracodorsal artery perforator flap for distal limbs reconstruction in 12 clinical cases, including three hands, two forearms and seven feet. The soft tissue defects resulted from trauma, scar release, chronic ulcer, or tumour ablation. The main advantages of the thoracodorsal artery perforator flap are that it contains no muscle, allowing more reconstructive precision, and morbidity is minimised by preserving the function of the latissimus dorsi muscle and hiding the donor scar. However, meticulous intra-muscular retrograde dissection of the perforator, to the thoracodorsal artery, is necessary in order to obtain suitable pedicle length and vessel diameter. The authors conclude that the free thoracodorsal artery perforator flap has greater potential for resurfacing large defects of distal limbs, because of its suitable thickness and hidden donor site.

Adult↗
PubMed2005

Anatomy of the proximal cutaneous perforator vessels of the gracilis muscle.

An anatomic study was performed to analyse the proximal perforator vessels of the gracilis musculocutaneous flap. Twenty-three cadaver legs preserved by the method of Thiel were carefully dissected 24h after the proximal vascular pedicle was injected with a red silicone mass. Nine additional cadaver legs were injected with ink, to visualise the skin area supplied by the proximal perforators, respectively, clarified by a modified Spalteholz technique to demonstrate the anatomic course of the perforators. A considerable variation in numbers and localisation of proximal cutaneous perforators was found. One to four perforators were seen within an area of 6 x 6 cm(2) at the entrance of the main pedicle into the proximal gracilis muscle. Their external diameter ranged from 0.5 to 1.0 mm. The ink-injections showed an oval shaped angiosome with a mean surface of 88 cm(2) at the level of the proximal gracilis pedicle. We conclude from this anatomic study, that a cutaneous flap based on the medial circumflex femoral gracilis perforators can be harvested by experienced hands bearing in mind the unpredictable perforator-anatomy.

Arteries↗
PubMed2006

Multidetector-row computed tomography in the planning of abdominal perforator flaps.

An accurate preoperative evaluation of the vascular anatomy of the abdominal wall is extremely valuable in improving the surgical strategy in abdominal perforator flaps. The multidetector-row computer tomography offers thin slice coverage of extended volumes with an extremely high spatial resolution. From October 2003 to December 2004, 66 female patients had breast reconstruction surgery in our department using the deep inferior epigastric artery perforator flap. Our multidetector-row computer tomography studies were performed using a 16-detector-row computer tomography scanner. The image assessment was carried out using the following protocol: we first identified the best three perforators from each side of the abdomen. Then we conducted a three-dimensional reconstruction of the abdomen by identifying exactly where the three best perforators emerged from the rectus abdominis fascia. We then transferred the data obtained from the image to the patient using a coordinate system. In addition, we also placed the dominant perforators in the patient by using a conventional hand-held Doppler. During the operation we compared intra-operative findings, Doppler results and computer tomography outcomes. Neither false positive nor false negative results were found in the computer tomography outcome. Multidetector-row computer tomography provides us with an easy method of interpreting the virtual anatomic dissection in three dimensions. It has high sensitivity and specificity and provides a good quality evaluation of the perforator vessels. This information allows reduction of operating time and safer performance of surgery. The multidetector-row computer tomography is a highly effective tool in the preoperative study of abdominal perforator flaps.

Abdomen↗
PubMed2007

Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors.

BACKGROUND: A flexible needle-catheter tissue-anchoring device was developed to accomplish full-thickness tissue apposition of the GI wall. The aim of this study was to identify the performance of this device for repair of large iatrogenic gastric perforations in a porcine model. OBJECTIVES: Six pigs. DESIGN: Short-term survival animal study. SETTINGS: Pigs were studied while they were under general anesthesia. Device performance in differing gastric locations and wall thicknesses was assessed by 2 perforations more than 2 cm in size created for each pig along the greater curvature and the anterior wall. INTERVENTIONS: Each perforation was closed by parallel placement of tissue anchor sets sequentially along the length of the perforation. MAIN OUTCOME MEASUREMENTS: One week follow-up endoscopy and necropsy were performed. RESULTS: Twelve perforations were closed with the 48 tissue anchor sets. All animals survived for 1 week without clinical complications. Follow-up endoscopy and necropsy revealed that all tissue anchors remained with firmly held sutures and sealed perforations. CONCLUSIONS: Full-thickness closure with a new tissue-anchoring device simply and successfully repaired large iatrogenic gastric perforations.

Animals↗
PubMed2006

The early use of a perforator flap of the lateral lower limb in maxillofacial reconstructive surgery.

The development of perforator-based flaps led to new donor sites and enlarged the spectrum of recipient vessels using arteries and veins of very small calibres. Although these flaps, which are directly anastomosed at their terminal cutaneous branches, are becoming more and more important for reconstructions in other regions of the body, perforator-based flaps have not played an important role in maxillofacial surgery until now. This study reports the experience with 24 consecutive perforator flaps from the lateral lower limb for intra- and extraoral defect coverage. Septo- or myoseptocutaneous perforators from the peroneal artery served as the flap pedicle having a length of 4-7 cm and diameters of 1-2 mm. Indications were reconstructions of the floor of the mouth (10), soft palate (3), tongue (6), closure of perforating cheek defects (2) and reconstruction of the facial skin (3). Anastomoses were performed to the lingual, facial, temporal or thyroid superior artery. Except for 2 cases, all perforator-based flaps were healed well and the morbidity of the donor site was nearly negligible. According to the early experience in this study, perforator-based flaps from the lateral lower limb may have an indication if recipient vessels available are close to the defect and if very low donor site morbidity is important to the patient.

Aged↗
PubMed2006

Repair of nasal septal perforations using auricular conchal cartilage graft in children: report on three cases and literature review.

OBJECTIVES: Repair of nasal septal perforation is a challenging procedure. Numerous methods have been described to close nasoseptal perforations with varying degrees of success. The lack of a consensus on nasoseptal perforation repair reflects the shortcomings of each method. There has been a paucity of literature on nasoseptal repair in the paediatric age group. We report our experience of repair of nasal septal perforation secondary to button battery injury using auricular conchal cartilage in the paediatric population. METHODS: Retrospective review of case notes and close regular follow-up of the patients since their first presentations with button batteries as foreign bodies in the nose. RESULTS: Three out of the three children who underwent repair of the nasal septum achieved successful closure of the nasal septum. One child with a large septal perforation required three procedures to achieve closure of the perforation. CONCLUSIONS: Repair of nasal septal perforations is a challenging procedure especially in children. Good results can be achieved with auricular conchal cartilage graft.

Child, Preschool↗