Acute Perforation Research Articles

To patch or not to patch acute isolated traumatic tympanic membrane perforations: a case series and systematic literature review.

To date, there is no consensus about the benefits of paper patching over spontaneous healing in the management of isolated acute traumatic tympanic membrane perforations (IATTMP). In this systematic literature review and case series, we compared paper patching of IATTMP to spontaneous healing in terms of healing rate and time to heal. A systematic literature search of English-language studies published from 1/1975 to 9/2020 was conducted using PubMed via MEDLINE, and 201 studies were identified. Another 346 studies were derived from the references of those articles. Twenty-four studies remained after omitting duplications and articles that did not meet the inclusion criteria. Demographics, medical history, physical examination, and audiometric results in the selected publications and in a new series of patients treated for IATTMP between 1/2018 and 1/2021 in a single tertiary referral center were retrieved and analyzed. The literature review yielded 2796 ears of which 466 underwent paper patching (intervention arm). Complete perforation healing was documented in 67-97% of control arm and 92-93% of intervention arm. Our new series included 29 ears of which six underwent paper patching. Complete healing was observed in 83% and 78% in the interventional and control arms, respectively. Although paper patching and watchful waiting had similar success rates in patients with IATTMP, healing after paper patching was slightly quicker among our patients. Patching is a readily applicable and technically simple office-based intervention that should be preferentially considered for IATTMP.

Abstract 13622: Current of Injury is an Indicator of Lead Depth and Acute Perforation During Left Bundle Branch Pacing Lead Implantation

Background: Left bundle branch(LBB)pacing has emerged as a favorable option that utilizes cardiac conduction system. Monitoring lead depth in the septum is crucial to reach the LBB area and to avoid lead perforation but lacks informative approach. We aimed to assess the hypothesis that current of injury (COI) is a useful tool in guiding depth of lead and forecasting perforation. Methods: Consecutive patients who received LBB pacing with distinct LBB potential were enrolled from January 2018 to December 2020. Unipolar intracardiac electrogram was recorded from both tip and ring electrode at the time of lead fixation. The maximum amplitude of ST-segment elevation from baseline was defined as COI. Results: LBB pacing lead implantation was attempted for 1223 times in 512 patients (age 66.25 ± 15.20 years, 310 male). Discrete COI (ST-segment elevation more than 25% of intrinsic R wave amplitude) was present in 92.70% of the cases (1134/1223) on tip electrode while only in 68.1% of the cases (833/1223) on ring electrode. COI tip/COI ring was correlated with the lead depth determined by sheath angiography (Spearman’s Correlation Coefficient=-0.624, p =0.000). Acute lead perforation has occurred in 11 cases when COI was either absent or very low on tip electrode. Among them, only eight cases, noted as microperforation, displayed significant COI on ring electrode, and COI tip/COI ring was extremely low (0.063, 0.035-0.123). The COI tip/COI ring<1 is associated to lead perforation (OR: 30.24, 6.47 -141.3, p=0.000). Sensitivity, specificity, and positive and negative predictive values of COI tip/ring<1 as an early marker for lead perforation were 81.8%, 87.1%, 54.2% and 99.8%, respectively. Conclusions: In conclusion, COI tip/ring could help to understand the depth of lead inside ventricular septum. Lack of COI on tip electrode or a very low COI tip/COI ring may signal lead perforation.

Histopathological Evaluation of Platelet-Rich Plasma Effect in Acute Tympanic Membrane Perforation.

The online version contains supplementary material available at 10.1007/s12070-021-02912-2.

1404 NELA Risk Mortality Scores from Admission to Theatre in Emergency Gastrointestinal Perforation – A Retrospective Cohort Study

Abstract Background Patients with acute abdominal pathology requiring emergency laparotomy who experience a delay to theatre have an increased risk of morbidity, mortality and complications. The aim of this study was to assess delay, from symptom onset to theatre in patients with gastrointestinal perforation and its effect on perioperative risk. Method A single-centre retrospective study was performed in the Leeds Trust Hospitals, UK investigating the NELA database for patients requiring emergency laparotomy for perforated gastrointestinal viscus who presented to the acute surgical unit or emergency department between 1st February 2018 and 31st January 2020. Results 101 patients met the inclusion criteria (47% F and 53% M), mean age 59 [21-91]. 37% of patients’ NELA scores worsened from admission to pre-op (median change of + 5.9% IQR 1.3-11.5]), 14% stayed the same and 49% improved (median change of -4.4%[IQR 0.4-9.1]) 3% had their NELA score documented at the time of consent. 18% did not wait for a CT report or went straight to theatre. Mean time from admission to scan report was 9.3 hours (0.9-22.0). Median time from symptom onset to presentation (2 days [IQR 1-13]) was greater in patients with an Index of Multiple Deprivation Decile of 1-5, (n = 64, median 2 days [IQR 1-6]) compared to those in deciles 6-10, (n = 37, median 1 day[IQR 1-3]), p = 0.097. Conclusions NELA mortality risk score changes from presentation to surgery in patients with acute gastrointestinal perforation requiring emergency laparotomy. There is suggestion that delay in symptom onset to presentation may correlate with Index of Multiple Deprivation Decile.

THE DEADLY PACE

TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Myocardial perforation remains as a rare but important complication of pacemaker insertion. Perforation can occur acutely within 24 h after implantation, sub-acutely between 24 h to one month after implantation and chronically occurring more than one month after implantation. (Sidhu). Acute perforations are well described at medical literature, but chronic perforations are much less common and can be difficult to diagnose (Ahmed). This is the case of atypical presentation of a chronic right ventricular perforation caused by RV ICD lead presenting with tamponade and left sided compression atelectasis. CASE PRESENTATION: A 73-year-old Male with PMHx of A-Fib, CHF class II, A-HTN, NIDDM, RA, PUD, TAA, S/P ICD placement 3 months before presentation, that comes to the ED with pleuritic chest pain, dizziness, SOB and fatigue of 3 months of evolution. Patient states that the symptoms slowly worsened over the last 3 days. At physical examination was found with BP 90/40, HR 105 bpm, RR 21rpm Sat 95% in acute distress, using accessory muscles with muffled heart sounds and + JVD. COVID-19 Ag was negative. EKG shows sinus tachycardia and low voltage on precordial leads. A bedside echocardiogram shows large pericardial effusion with tamponade physiology, ventricular perforation and emergent pericardiocentesis was performed. A total of 515 ml of bloody pericardial fluid was removed and patient vital signs improves. Chest CT scan later confirmed the presence of pericardial fluid accumulation and left sided compression atelectasis. The ICD lead was removed and relocated at the ventricular septum to avoid ventricular perforation in the future. DISCUSSION: In rare circumstances when a large effusion develops over time, it may cause compression atelectasis of the surrounding bronchi and lung (Amin). Compression atelectasis caused by ventricular perforation are better described in cases of acute or subacute ventricular perforation at the medical literature. The most common presentation of chronic perforation is SOB and hypoxemia. This patient presentation after 3 months of ICD placement, with sudden onset cardiac tamponade and no hypoxemia is an atypical presentation of chronic ventricular perforation. The rapid fluid accumulation over time in the pericardium, is what causes that this space stretches to accommodate the excess fluid, that later cause a compression atelectasis of the surrounding bronchi and lung (Amin). CONCLUSIONS: This patient atypical presentation of ventricular perforation wasn't described before in the literature. Is very important not to assume that any perforation may the sequelae of a recent intervention and can present acutely like in this life-threatening clinical scenario. As clinicians we need to keep in mind that ventricular perforation may present with large effusion causing compression atelectasis, with or without tamponade physiology. REFERENCE #1: Sidhu B, Rajani R, Rinaldi C. Chronic Ventricular lead perforation: Expect the Unexpected. Clin Case Rep. 2019, 7: 455-468 REFERENCE #2: Ahmed A, Shokr M, Lieberman R. Subacute right ventricular perforation by pacemaker lead causing left sided hemothorax and epicardial hematoma. Case Reports in Cardiology. 2017: 1-5 REFERENCE #3: Amin H, Gyawali B, Chaudhuri D. A large pericardial effusion culminating in left lung collapse. Cureus. 2019, 11: e5287 DISCLOSURES: No relevant relationships by Jesse Aleman, source=Web Response No relevant relationships by Francisco Caraballo, source=Web Response No relevant relationships by Greisha Gonzalez Santiago, source=Web Response

Management of complications after paraesophageal hernia repair

: Laparoscopic paraesophageal hernia (PEH) repair can be performed safely in expert hands. However, it is a complex operation carrying significant risk of peri-operative morbidity and mortality. Careful intra-operative correctional techniques and prompt return to theatre for early post-operative complications result in a satisfactory outcome. Capnothorax and pneumothorax should be dealt with immediately by lowering insufflation pressure, aspiration and drain placement. Hemodynamic instability from cardiovascular injury or bleeding mandates an early return to theatre. Intra-operative perforation of the esophagus or stomach is best avoided, but it can be successfully repaired. Early acute dysphagia warrants a return to theatre for correction while delayed dysphagia can in some patients be treated by dilatation. Asymptomatic hiatus hernia recurrence does not require surgery, but symptomatic and complicated hernias can be re-repaired. Some life-threatening complications such as acute gastric dilatation, aortic fistula, gastric necrosis and perforation can occur months, and even years, after the procedure. Other complications that can severely impair quality of life in the longer term include esophago-gastric junction stenosis, hiatus hernia recurrence, delayed gastric emptying and excess intestinal gas. Longer term revisional surgery for life-threatening or life-impairing complications can be done safely by expert surgeons but has a lower chance of success than primary surgery.

S3692 Rapid Deterioration of Metastatic Adenocarcinoma of the Lung Into an Acute Bowel Perforation

S3692 Rapid Deterioration of Metastatic Adenocarcinoma of the Lung Into an Acute Bowel Perforation

S3172 Mixed Type Gastric Adenocarcinoma Presenting as Acute Gastric Perforation in a Young Adult: Can Crack Cocaine Cause Early Onset Perforation or Gastric Carcinoma Itself?

S3172 Mixed Type Gastric Adenocarcinoma Presenting as Acute Gastric Perforation in a Young Adult: Can Crack Cocaine Cause Early Onset Perforation or Gastric Carcinoma Itself?

Eardrum perforation treatment blood plasma enriched with platelet growth factors

Introduction. The problem of the development of acute post-traumatic otitis media has not lost its relevance. Long-term preservation of the defect of the tympanic membrane contributes to the development of chronic inflammation in the middle ear and a deterioration in the quality of life of patients.Objective. To study the effect of blood plasma enriched with platelet growth factors on the regeneration of the tympanic membrane tissues in patients with acute post-traumatic perforation.Materials and methods. Patients with acute post-traumatic perforation of the tympanic membrane were divided into the main (24 people) and control (19 people) groups. Patients of the main group in the area of perforation of the tympanic membrane were injected once by application with a clot of autoplasma, enriched with platelet growth factors. The control group patients underwent dynamic observation of the processes of natural regeneration of the tympanic membrane tissues. On the 5, 10 and 15th days, the tissue regeneration of the tympanic membranes was assessed subjectively (patient complaints, audiometry) and objectively (otoscopy with the calculation of the dynamics of the relative perforation area, otoacoustic emission).Results. A single application of blood plasma enriched with platelet growth factors to the perforation area was significantly more often accompanied by closure of the tympanic membrane perforation (p ≤ 0.01) and a decrease in the average relative area of the tympanic membrane perforation on days 10 and 15 of the study (p ≤ 0.01). The dynamics of the average relative area of the tympanic membrane perforation reflected a high rate of closure of the tympanic membrane defect in the main group. Better healing of the tympanic membrane in patients of the main group was accompanied by an improvement in the auditory function of the affected ear. The quality of hearing was, on average, significantly better in the patients of the main group than in the patients of the control group, both on the 10th and 15th days of observation (p ≤ 0.01).Conclusion. Clinical use of blood plasma enriched with platelet growth factors has a beneficial effect on the rate, intensity of closure of the tympanic membrane perforation and hearing.

Hubungan antara Usia, Lama Keluhan Nyeri Abdomen, Nilai Leukosit, dan Rasio Neutrofil Limfosit dengan Kejadian Apendisitis Akut Perforasi di RSUD Abdul Wahab Sjahranie Samarinda

Acute appendicitis is an infection that occurs in the appendix vermiformis or commonly known in the community with inflammation of the appendix. The incidence of appendicitis in the world is quite high and diagnosis is still a challenge in surgery. Delay in establishing a definite diagnosis of appendicitis has implications for suboptimal management and can lead to complications in the form of perforation. Perforation of the appendix vermiformis will result in peritonitis and can cause uncontrolled sepsis and intra-abdominal abscess. Age and delay in diagnosis are factors that play a role in the occurrence of perforation of the appendix vermiformis. The longer the complaint of abdominal pain experienced in acute appendicitis, the higher the possibility of perforation. Leukocyte count and lymphocyte neutrophil ratio is a laboratory test that can help diagnose acute appendicitis. The purpose of this study was to determine the relationship between age, duration of abdominal pain, leukocyte value, and neutrophil lymphocyte ratio with the incidence of acute appendicitis perforation. The design of this study uses a cross-sectional study with observational analytic methods. Data were taken from the medical records of patients with a diagnosis of acute appendicitis who received appendectomy at the Abdul Wahab Sjahranie Samarinda Regional General Hospital for the period 2018-2019 using purposive sampling technique and obtained 105 research samples. Bivariate analysis was performed using the chi-square test and fisher test if the expected count less than 5. The analysis results obtained a significant relationship between age (p=0,015), duration of abdominal pain (p=0,000), leukocyte value (p=0,049), and neutrophil lymphocyte ratio (p= 0,000) with the incidence of acute appendicitis perforation.

Emergency pancreatoduodenectomy with adenocarcinoma of the pancreas head, complicated by acute perforation of ulcer of the duodenum

Emergency pancreatoduodenectomy with adenocarcinoma of the pancreas head, complicated by acute perforation of ulcer of the duodenum

FGF2 and EGF for the Regeneration of Tympanic Membrane: A Systematic Review.

Objective A systematic review was conducted to compare the effectiveness and safety of fibroblast growth factor-2 (FGF2) and epidermal growth factor (EGF) for regeneration of the tympanic membrane (TM). Methods The PubMed database was searched for relevant studies. Experimental and clinical studies reporting acute and chronic TM perforations in relation to two healing outcomes (success rate and closure time) and complications were selected. Results A total of 47 studies were included. Five experimental studies showed closure rates of 55%–100% with FGF2 compared with 10%–62.5% in controls for acute perforations. Five experimental studies showed closure rates of 30.3%–100% with EGF and 3.6%–41% in controls for chronic perforations. Two experimental studies showed closure rates of 31.6% or 85.7% with FGF2 and 15.8% or 100% with EGF. Nine clinical studies of acute large perforations showed closure rates of 91.4%–100% with FGF2 or EGF. Two clinical studies showed similar closure rates between groups treated with FGF2 and EGF. Seven clinical studies showed closure rates of 88.9%–100% within 3 months and 58%–66% within 12 months using FGF2 in repair of chronic perforations, but only one study showed a significantly higher closure rate in the saline group compared with the FGF2 group (71.4% vs. 57.5%, respectively, P = 0.547). In addition, three experimental studies showed no ototoxicity associated with FGF2 or EGF. No middle ear cholesteatoma or epithelial pearls were reported, except in one experimental study and one clinical study, respectively. Conclusions FGF2 and EGF showed good effects and reliable safety for the regeneration of TM. In addition, EGF was better for the regeneration of acute perforations, while FGF2 combined with biological scaffolds was superior to EGF for chronic perforations, but was associated with high rates of reperforation over time. Further studies are required to determine whether EGF or FGF2 is better for TM regeneration.

Case presentation on a rare cause of small bowel obstruction- trichobezoar: a case report

Trichobezoars are concretions of swallowed hairs retained within the digestive tract, most commonly stomach. Most common in young females and with psychiatric illness. Trichobezoar may be a cause of acute abdomen when it is complicated with acute obstruction or perforation. In this report we present a case of young girl who presented as an acute obstruction due to two large ileal trichobezoars.

A Quality Improvement Project on the Development of an Evidence-Based Management Algorithm for Iatrogenic Endoscopic Perforations and the Long Term Impact on Physician Knowledge

Acute iatrogenic endoscopic perforations (AIEP) can lead to serious complications and death. If identified immediately, perforations can be closed endoscopically with a 90% success rate. Knowledge of AIEP may decrease the associated morbidity and mortality.

Perioperative Challenge in Anesthetic and Pain Management in a Case of Hepatitis E and Typhoid Co-infection with Acute Liver Failure and Ileal Perforation: a Case Report and Review of Literature

Perioperative Challenge in Anesthetic and Pain Management in a Case of Hepatitis E and Typhoid Co-infection with Acute Liver Failure and Ileal Perforation: a Case Report and Review of Literature

Tympanic membrane regeneration using platelet-rich fibrin: a systematic review and meta-analysis.

Platelet-rich fibrin (PRF) results in satisfactory wound healing. This analysis focuses on assessing the effectiveness of PRF in the treatment of tympanic membrane (TM) perforations. The literature was searched using PubMed, Embase, Cochrane Library and Web of Science databases from inception to February 28th, 2021. The following healing and hearing outcomes were measured: closure rate, pre-and postoperative auditory results, and incidence of postoperative infections. Data were pooled and expressed as the odds ratio (OR). Ten studies were eligible for qualitative review, and seven of them were included for the final quantitative comparison. The OR for the closure rate of acute perforations was 4.30 (95% CI 1.35-13.70, I2 = 0%), and the OR in the chronic subgroup was 5.42 (95% CI 2.57-11.43, I2 = 0%). The total OR value for the completed closure rate was 5.10 (95% CI 2.72-9.54, I2 = 0%), indicating that the utilization of PRF can enhance the closure of both acute and chronic perforations. The qualitative review did not find improved hearing results with the use of PRF. In addition to promoting closure, PRF can reduce the incidence of infections (OR = 0.14). The sensitivity analysis did not change the final results, and there was no publication bias in this analysis. PRF can increase the closure rate of acute perforations, enhance the survival rate of autografts in TM surgeries and reduce the incidence of infections. However, the literature indicates that PRF does not influence the hearing outcomes. This study shows that PRF is an effective agent for TM regeneration.

Paradigm shift in management of acute iatrogenic colonic perforations: 24-year retrospective comprehensive study.

Background and study aims Through advanced endoscopic clipping techniques, endoscopic treatment of both diagnostic and therapeutic acute iatrogenic colonic perforations has been shown effective. The main purpose of this study was to compare the management of acute iatrogenic perforations (AIPs) of the colon before and after the introduction of advanced clipping techniques. Methods We conducted a retrospective study from July 1996 to February 2020. The period was divided into two sub periods, Period 1: from July 1996 to December 2012 and Period 2: from January 2013 to March 2020. All AIPs occurring during a colonoscopy and detected during or immediately (< 4 hours) after the procedure, were included in the study. Results The total number of colonoscopies performed at our hospital was 33055 and 36831 during Periods 1 and 2 respectively. Fifteen perforations were observed in Period 1 and 11 in Period 2. The rate of surgery was 93.3 % % (14/15) in Period 1 and 27.2 % (3 /11) in Period 2 ( P < 0.01). The mean hospital stay in Period 1 was 6.9 days and 4 in Period 2 ( P < 0.01). Conclusions Data from this historical cohort have clearly shown a decrease in the surgery rate and the length of hospitalization of AIPs in Period 2 compared to Period 1.

MALIGNANT SMALL BOWEL OBSTRUCTION: OUTCOMES OF PALLIATIVE SURGERY

Abstract INTRODUCTION Surgical management of malignant bowel obstruction (MBO) represents a surgical challenge associated with high morbidity and mortality, readmission and re-obstruction rates. The aim of this study is to describe the postoperative outcomes of palliative surgery for MBO in order to provide a guide for oncologists, surgeons and patients. MATERIAL AND METHODS Retrospective descriptive study in a tertiary referral centre of all the patients operated of an acute bowel obstruction or bowel perforation due to peritoneal carcinomatosis between January 2015 and December 2019. RESULTS Fifty-one patients were included in the study. Time from index surgery to clinical recurrence as MBO was 21±27 months. The indication for surgery was acute obstruction in 92.2% and bowel perforation in 7.8% of the patients. Intraoperative complications were found in 24% of the patients. Postoperative complications were found in 71% of the patients. Postoperative mortality was 16%. Length of stay was 31±26 days with a median postoperative stay of 20±16 days. Time to reobstruction in the whole series was 216±240 days. 90-day mortality was 31%. The median overall survival of patients that survived the first 90 postoperative days was 286.45±281.14 days (9.5 months). Most of the patients who survived the 90-postoperative days received systemic treatment (66%). CONCLUSIONS Palliative surgery for MBO is associated with high rates of postoperative complications and mortality. Well-selected patients that survive the first 90 postoperative days may have a long symptom-free period and longer survival.

The modern approach to esophageal palliative and emergency surgery.

Thoracic surgeons currently have multiple options and strategies to guide treatment in esophageal palliative and emergency conditions. To guide the selection of an individualized palliative approach, physicians, including thoracic surgeons, must take into consideration many factors including prognosis, performance status and comorbidities of patients. For dysphagia more specifically, esophageal stent placement is the most widely used intervention for rapidly relieving dysphagia in inoperable esophageal cancer patients. The combination of esophageal stent placement with other therapies has an impact on palliative care. Innovations including radioactive stents, drug-eluding stents and biodegradable stents will require further evaluation and validation studies. Currently, patients with inoperable esophageal cancer have access to oncological and biological therapies that are improving their prognosis. A shift toward restaging and potential curative intent is occurring in current clinical practice. In acute intrathoracic esophageal perforation cases, high index of suspicion, multidisciplinary team expertise, antibiotics and hybrid treatment strategies, have significantly improved outcomes of patients in recent years. Hybrid treatment strategies denote the combination of minimally invasive interventions for source control and endoluminal procedures to seal the esophageal perforation. Endoluminal procedures as treatment of acute intrathoracic esophageal perforation include stent placement, over-the-scope clip and endoluminal vacuum therapy. Future perspective in the management of esophageal perforation seems to be the combination of endoluminal therapies tailored to the specific clinical scenario. Thoracic surgeons benefit from mastering endoluminal therapies and advanced endoscopic techniques. An understanding of these rapidly evolving therapies, i.e., outcomes, limitations and innovations, is required to optimally manage esophageal palliative and emergency conditions.

Analysis of Curative Effect of Subtotal Gastrectomy and Simple Repair for Acute Gastric Perforation

Analysis of Curative Effect of Subtotal Gastrectomy and Simple Repair for Acute Gastric Perforation