Common Site Of Perforation Research Articles

SPECTRUM OF PERFORATION PERITONITIS IN WESTERN NEPAL

Introduction: Despite advances in surgical technique, antimicrobial therapy and perioperative care morbidity and mortality in perforated peritonitis is still high. Aim of this study was to highlight the clinical presentation, intra operative findings and postoperative complications and mortality among patient who has undergone emergency surgery for perforated peritonitis in tertiary care center in western Nepal.Materials and Methods: This was a retrospective descriptive study carried out in Universal College of Medical Sciences, Bhairawha, Nepal. All patients who underwent emergency exploratory laparotomy for perforated peritonitis in one year period (from April 2014 to March 2015) were included in the study.Results: Total 90 cases met inclusion criteria and were analyzed. Most common presenting symptom was pain abdomen. Pneumoperitoneum was seen in 86 (95.6%) patients. Most common site of perforation was prepyloric perforation followed by duodenum. Most common cause of perforation was Acid peptic disease. Most common surgical procedure performed was Omentopexy. There were total of 11 (12.2%)mortality.Conclusion: The spectrum of perforation peritonitis in our study differs from western countries whereas it is similar to that of other research from Indian subcontinent. Majority of perforations are noticed in the duodenum and stomach due to acid-peptic disease and small bowel typhoid followed by trauma. Overall mortality was seen in 12.2%.Journal of Universal College of Medical ScienceVol. 6, No. 1, 2018, Page: 11-13

Gastroduodenal perforation in the pediatric population: a retrospective analysis of 20 cases.

The aim of this study was to investigate the pathogenesis, symptoms and individualized surgical management in pediatrics with gastroduodenal perforation (GDP). Patients diagnosed with GDP from January 2013 to December 2016 in our hospital were collected and divided into gastric perforation (GP) group and duodenal perforation (DP) group. Demographics, clinical events, etiological factors, symptoms, the time from symptom onset to operation, intraoperative findings and surgical procedures were analyzed. Follow-ups including ulcer, perforations occurrence, and digestive symptoms were carried out by out-patient review or telephones. A total of 20 patients aged from 3months to 14years were enrolled in this study. The average age, main clinical presentations, size of perforations and operating time between two groups had no difference. The male to female ratio in DP group was higher than GP (P < 0.05). The high risk factor for DP was the use of dexamethasone, and for GP was HP infection. The most common site of perforation in DP group was duodenal bulb, and in GP group was pylorus area. Simple suture is the main management for both DP and GP, but distal gastrectomy combined with gastrojejunal Roux-en-Y anastomosis may be an alternative procedure for large perforation with diameter > 2cm. The length of hospital days in GP group is shorter than DP group (P < 0.05). For follow-up, no patients had digestive symptoms. The general condition had no difference between GP and DP patients. But the risk factors and surgical repair differ depending on the patient's fundamental illness and the complexity of the perforation.

Clinical efficacy of two anti-microbials (ceftriaxone and metronidazole) versus three antimicrobials (ceftriaxone, metronidazole and amikacin) in perforative peritonitis

Background: Peritonitis is classified as primary, secondary and tertiary. In primary peritonitis and continuous ambulatory peritoneal dialysis-associated peritonitis, the source of the infection is not due a breach in the gastrointestinal tract and usually caused by a single organism. Secondary peritonitis ensues, which may be localized and contained or diffuse carrying a high mortality in the absence of surgical intervention and appropriate antimicrobial therapy. In contrast, secondary peritonitis following perforation of the gastrointestinal tract or an infection originating in an intra-abdominal structure. Tertiary peritonitis is an ill-defined entity, which occurs despite adequate treatment of primary or secondary peritonitis.Methods: This is a prospective clinical study conducted on 140 consecutive patients who presented to the surgical department of RL Jalappa Hospital and Research Centre, Tamaka, Kolar with peritonitis secondary to hollow viscus perforation.Results: A total of 140 patients who presented with peritonitis secondary to hollow viscus perforation, admitted and treated in RL Jalappa Hospital and Research Centre attached to Sri Devaraj Urs Medical College, Kolar were studied during the period of December 2015 to June 2017.There was decrease in postoperative complications and hospital stay in Group B.Conclusions: In present study peritonitis is more common in men compared to women. The most common age group is in between 21-40 years in cases of peritonitis with the mean age of 37 years. Duodenal ulcer perforation is the commonest site of perforation. Escherichia coli is the most common organism isolated in the peritoneal fluid. usage of three antimicrobials (p&lt;0.05) is beneficial in reduction in postoperative complications and hospital stay when compared to usage of two antimicrobials which is statistically significant.

Decrease in uterine perforations with ultrasound image-guided applicator insertion in intracavitary brachytherapy for cervical cancer: A systematic review and meta-analysis

PurposeTo estimate uterine perforations rates during intracavitary brachytherapy for cervical cancer with and without ultrasound (US) image guidance. Materials and methodsA systematic search of databases (PubMed and EMBASE) was performed. The pooled summary uterine perforation rate (detected by postinsertion CT or MRI) for the un-guided insertion group and the guided insertion group was calculated by using the random-effects model weighted by the inverse variance. ResultsA total of 690 articles were initially found, resulting in 12 studies that met the inclusion criteria. A total of 1757 insertions and 766 patients were included in the meta-analysis. The overall uterine perforation rate per insertion was 4.56% (95%CI: 2.35–8.67) and per patient was 7.39% (95%CI: 3.92–13.50). The pooled perforation rate per insertion without image guidance was 10.54% (95%CI: 6.12–17.57) versus 1.06% (95%CI: 0.41–2.67) with image guidance (p < 0.01). The pooled perforation rate per patient without guidance was 16.67% (95%CI: 10.01–26.45) versus 2.54% (95%CI: 1.21–5.24) with image guidance (p < 0.01). The ratio of perforations in the un-guided/guided groups was 9.94 and 6.56, per insertion and per patient, respectively. The most common sites of perforation were the posterior wall (>47 events) and the uterine fundus (24 events). None of the studies reported significant acute clinical consequences. Prophylactic antibiotic after perforation was used in 3 of the 4 studies that described the management. ConclusionUsing postinsertion CT or MRI to detect the perforation, the rate of uterine perforation per insertion in patients who received US-guided intracavitary brachytherapy insertion is 90% lower than with un-guided insertion.

Clinical Outcomes of Endoscopy-Associated Perforation (EAP) in Patients With Inflammatory Bowel Disease (IBD)

Introduction: Frequent endoscopic procedures and chronic mucosal inflammation increases the risk of endoscopy-associated perforations (EAP) in patients with inflammatory bowel disease (IBD). But, data is lacking on their clinical course and appropriate management. We aim to assess the clinical outcomes and management of EAP in IBD patients. Methods: In this retrospective study, all IBD patients at our tertiary care center who underwent endoscopic procedures between January 2000- December 2015 and had an EAP were included. Patients with incomplete medical records or unfirmed IBD were excluded. Data on demographics, IBD, medications and labs within 48 hours of procedure was collected. Type of procedure, procedural difficulty, symptoms and imaging results were also collected. Clinical outcomes were assessed by need of endoscopic/surgical interventions, hospitalization, and death.Unadjusted and multivariable logistic regression analysis was used to assess factors associated with need for intervention. Results: Out of 166 reviewed cases, 44 patients with confirmed IBD and EAP were included in the final analysis.Median age at EAP was 42 years, with a median IBD duration of 3.8 years. 55% were females and 40% were current or former smokers. Crohn's disease (CD) was present in 56.8%, UC in 29.5% and rest had intermediate colitis. 27.3% were on biologic therapy, 13.6% on immunomodulators and 13.6% were on systemic steroids. Colonoscopy was the most common procedure (53.5%) and procedural difficulty was encountered in 24.3 %. After EAP, 95.5% had clinical symptoms and 96% had free air on imaging. Terminal ileum was the most common site of perforation (34.5%), followed by ileocecal anastomosis (20.7%). Laparoscopic interventions were performed in 11.4% and 54.5% required surgical interventions, colectomy with ileostomy being the most common (25%). Most of these surgeries were open procedures (87.5%). All patients with EAP required hospitalization and antibiotics (except one), 32.6% were admitted to ICU, 28.2% had sepsis, 14.5% had AKI, and 4.5% died (Table 1). After adjusting for age, a 25 unit increase in platelet count is associated with 20% higher odds of requiring intervention for EAP. Conclusion: EAP in IBD patients is associated with significant morbidity and can further complicate the disease course. Surgical management is the mainstay of therapy in patients who require any intervention for EAP. Further studies are required to identify high risk procedures and means to decrease the risks.582 Figure 1 No Caption available.

Surgery in perforated pediatric intestinal lymphoma

BackgroundPerforation is the most common surgical complication in pediatric intestinal lymphoma. During operation, many surgical decisions are debatable. AimTo assess the outcome of surgical management of perforated pediatric intestinal lymphoma. Patients and methodsThis is a retrospective analysis of all pediatric patients (<18 years old) with intestinal lymphoma treated in our hospital between July 2007 and June 2017. Risk factors for perforation, type of management and outcome in cases of intestinal perforation were analyzed. ResultsThe study included 240 patients with intestinal lymphoma. Perforation developed in 16 patients (6.7%) with a median age of 5.3 (range: 2.8–15.7) years. Most of the patients (92.5%) had Burkitt lymphoma. The ileum was the most common site of perforation (n = 10). Perforation occurred at presentation (n = 2), during induction (n = 10), during maintenance chemotherapy (n = 2), or at relapse (n = 2). Primary resection anastomosis was done in 12 patients. The resected specimen showed a viable tumor in ten patients. Wound infection (25%) and dehiscence (12.5%) were the most common postoperative complications. The 5-year overall and event-free survivals of patients with perforation were 78.6% and 71.4%, respectively, compared with 85.5% and 81.2% in non-perforated patients; the difference was not significant (p = 0.374 and p = 0.270, respectively). ConclusionPerforation is not an adverse prognostic factor for survival in pediatric intestinal lymphoma patients. Primary resection anastomosis seems to be a safe option if complete tumor resection is feasible.

Laparoscopic repair using an endoscopic linear stapler for management of iatrogenic colonic perforation during screening colonoscopy.

IntroductionColonoscopy is a safe and effective procedure, but it is also an inevitably invasive one. Laparoscopic repair of colonoscopic perforations has been reported to be a safe and effective treatment.AimWe present our surgical technique and outcomes of laparoscopic repairs using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy.Material and methodsLaparoscopic repair using an endoscopic linear stapler for iatrogenic colonic perforation during screening colonoscopy was performed by two experienced laparoscopic surgeons on 14 consecutive patients between April 2010 and December 2017 at our hospital. Using prospectively collected data, an observational study was performed on a per protocol basis.ResultsThe mean age of the 14 patients who underwent laparoscopic repair was 56.6 ±9.1 years. The most common perforation site was the sigmoid colon in 10 (71.4%) patients, followed by the rectosigmoid junction in 3 (21.4%) patients and the splenic flexure in 1 (7.1%) patient. The median perforation size was 10 (range: 5–30) mm. The mean operation time was 73.9 ±28.2 min. Postoperative complications occurred in 1 (7.1%) patient. There was no postoperative mortality or reoperation within 30 days after surgery. The median time to tolerance of a regular diet was 5 (range: 3–6) days. The median postoperative hospital stay was 8.5 (range: 5–15) days.ConclusionsLaparoscopic repair using an endoscopic linear stapler is a safe, easy, and effective surgical technique to treat colonic perforation related to screening colonoscopy.

Outcome of gastrointestinal perforations due to blunt abdominal trauma

Background: The most common injury during blunt abdominal trauma (BAT) is of solid organs. Hollow viscus injuries are much more uncommon compared to the non-hollow ones. The most important problem associated with these conditions that they are frequently remain undetected or diagnosed too late despite advanced techniques such as focussed abdominal sonography for trauma (FAST), computer tomography, and magnetic resonance imaging. This study evaluates gastrointestinal perforation following blunt abdominal trauma, their anatomical distribution, diagnosis, management, and outcome.Methods: The study was a prospective observational study conducted after ethical clearance from hospital. The patients included were those presenting with features of peritonitis following blunt trauma, with isolated injury to abdomen and found to exhibit gastrointestinal perforation on exploratory laparotomy. Exclusion criteria were perforation was not detected at surgery, penetrating abdominal trauma. Data of each patient were collected into the Performa prepared for the study.Results: During the study period, 32 patients underwent surgery for perforation following blunt abdominal trauma. Jejunum was the most common site of perforation in the study subjects followed by ileum than stomach. Among the procedures performed, simple closure of perforation with peritoneal lavage was the most commonly performed procedure in 24 patients (75.0%). Resection anastomosis was done in 3 (9.3%) cases, while stoma was fashioned in 5 (15.6%) patients. 5 (15.6%) patients developed complications in the postoperative period with chest infection being the most common. One patient died in the postoperative period leading to mortality rate of 3.1%.Conclusions: To conclude, early diagnosis and treatment are of utmost importance. Most common site for perforation in blunt trauma is jejunum. Early surgery following adequate resuscitation in gastrointestinal perforation following blunt trauma abdomen is associated with a very a good outcome.

Clinical evaluation of patient with perforation peritonitis and their peritoneal fluid analysis for culture and sensitivity

Background: Perforation peritonitis is one of the most common emergency that is encountered by surgical unit in emergency department and timely management of it can prevent morbidity and mortality, its important to reach the diagnosis earliest and intervene immediately. we find that understanding the peritoneal fluid obtained on exploratory laparotomy and knowing its culture and sensitivity and treating with appropriate antibiotic has a significant role in better management and early recovery of such patients.Methods: This study comprises of 100 consecutive cases of acute perforation peritonitis on whom exploratory laparotomy was done. In a study period from 1/4/2016 to 13/7/2017 conducted by department of General surgery Government medical college Haldwani-Nanital. Diagnosis was made on basis of clinical and radiological examination. Peritoneal fluid sample was obtained after opening the peritoneum and sent for peritoneal fluid analysis to microbiology department to get culture and sensitivity.Results: Male to female ratio was 3:1 and the most common age group involved was between 20 to 40 years. The most common site of perforation was found to be duodenum amounting to 55% of cases followed by ileal perforation found in 20% cases, gastric perforation was found in 10 % of case. Most common microorganism among Gram negative organism was Klebsella found in 52% cases followed by E. coil in 36% cases, both were found together in 5% cases in rest of the cases proteus and pseudomonas were found. Sensitivity was found to ceftrioxone,ciprofloxacillin and amikacin in more than 87% of gram negative organism while resistance was seen to amplicillin and clotrimoxazole other antibiotics that showed sensitivity to microorganism were Linizoild and minocycline in 76% cases. Around 8% fluid showed presence of methecillin resistant or sensitive Staphylococcus aureus and both were sensitive to linizoilid and minocycline and resistant to penicillin, erythromycin and cephxatin.Conclusions: Peptic ulcer perforation is found to be most common site of perforation where second part of the duodenum supersedes Gastric perforation ratio been 5:1 jointly they are responsible for 65% of perforations. Second most common cause of perforation was due to enteric fever causing ilial perforation which was seen in 20% of the cases. Most common microorganism found is Klebsella and E. coli found in almost 81% of the case and were found to be sensitive to ceftrioxone, amikacin, linizoild and minocycline in almost all the cases.

Typhoid ileal perforation: a two-year study at a tertiary care hospital of South India

Background: Typhoid fever is an acute febrile illness caused by gram negative bacilli, Salmonella enteritidis serovars typhi. The incidence of typhoid fever varies globally from 140 episodes per 10000-person years in Kolkata to 273 per 10000 in Delhi, India. The present study was done with an aim to assess the risk factors, complications and different surgical techniques in cases of typhoid ileal perforation. The study also identifies and focuses on the post-operative complications in cases of perforation due to typhoid fever.Methods: A prospective study was conducted for a period of two years from June 2105 to May 2017 at a tertiary care hospital on all the cases admitted and operated for typhoid perforation. The data collected was analyzed using SPSS version 15.0 for windows 7.Results: 104 cases with an incidence rate of 8.4% of perforation were included in the study. Males were majority and mean age of the study group was 21.8±10.1 years. The peak incidence of study group was 31-40 years and &gt;60 years. Fever and abdominal pain (rebound tenderness) was the common sign and symptoms. Free fluid and air collection under the diaphragm was the commonest finding in radiographs and ultrasound. Majority of the cases had single perforation (84.62%) and ileum was the most common site of perforation (84.62%). Simple closure with double layering was the commonest surgical procedure performed and the incidence of post-operative complication was 36.5%. Overall mortality in the study was 3.8%. SSI was the commonest post-operative complication.Conclusions: To conclude from our study, typhoid still remains as an endemic disease in spite of improved awareness and better sanitation facilities. Inadequate treatment, misdiagnosis and mismanagement of cases by non-medical practitioners at rural settings may increase the risk of complications

“CLINICAL EFFICACY OF TWO ANTIMICROBIALS (CEFTRIAXONE AND METRONIDAZOLE) VERSUS THREE ANTIMICROBIALS ( CEFTRIAXONE , METRONIDAZOLE AND AMIKACIN )IN PERFORATIVE PERITONITIS

BACKGROUND : Peritonitis is classified as primary, secondary and tertiary. In primary peritonitis (spontaneous bacterial peritonitis) and continuous ambulatory peritoneal dialysis-associated peritonitis, the source of the infection is not due a breach in the gastrointestinal tract and usually caused by a single organism. Secondary peritonitis ensues, which may be localized and contained or diffuse carrying a high mortality in the absence of surgical intervention and appropriate antimicrobial therapy. Another sequelae of perforated viscus is intra-abdominal abscesses, located in the intra or retroperitoneal space, which occur in partially treated diffuse peritonitis, postoperatively or in localized disease where the omentum has sealed off the perforation and formed an inflammatory barrier. In contrast, secondary peritonitis following perforation of the gastrointestinal tract or an infection originating in an intra-abdominal structure, e.g. gall bladder, pancreas etc. Tertiary peritonitis is an ill-defined entity, which occurs despite adequate treatment of primary or secondary peritonitis. Combination antibiotic therapy has been used to provide the patient with broad-spectrum coverage against the many potential pathogens encountered in abdominal sepsis. Several potential benefits of the clinical use of antibiotic combinations have been advanced. So this study will be conducted to focus on the efficacy of combination of two versus three antimicrobial drug in the management of patients with perforated peritonitis. OBJECTIVES OF THE STUDY: 1.To assess the efficacy of two antimicrobials(Ceftriaxone And Metronidazole) in perforative peritonitis. 2.To assess the efficacy of three antimicrobials(Ceftriaxone, Metronidazole And Amikacin)in perforative peritonitis. 3.To compare the clinical outcome of perforative peritonitis with two and three antimicrobials in the terms of reduction in postoperative infections and hospital stay. MATERIALS AND METHODS SOURCE OF DATA: This is a prospective clinical study conducted on 140 consecutive patients who presented to the surgical department of R. L. Jalappa Hospital and Research Centre, Tamaka, Kolar with peritonitis secondary to hollow viscus perforation. Study period was from December 2015 to June 2017. This is a randomized study and all the patients were divided in two groups. GROUP A: Patients with all odd serial numbers were included in this group and treated with two antimicrobials (Inj Ceftriaxone 1gm IV BD and Inj Metronidazole 500mg IV TID). GROUP B: Patients with all even serial numbers were included in this group and treated with three antimicrobials(Inj Ceftriaxone 1gm IV BD , Inj Metronidazole 500mg IV TID and Inj Amikacin 500mg IV BD). INCLUSION CRITERIA : 1.Patients with peritonitis secondary to hollow viscus perforation. 2.Patients with age >18years and <70years. EXCLUSION CRITERIA: 1.Peritonitis secondary to trauma to the abdomen. 2.Peritonitis secondary to gynaecological interventions like D&C. 3.Peritonitis secondary to malignancies and immuno-compromised state 4.Patients allergic to Ceftriaxone, Metronidazole and Amikacin. 5.Tertiary peritonitis. RESULTS: The clinical outcome in the form reduction in postoperative complications and hospital stay were assessed in 140 patients, in Group A( with the usage of two antimicrobials , Ceftriaxone and Metronidazole) and Group B( with usage of three antimicrobials, Ceftriaxone, Metronidazole and Amikacin). There was decrease in postoperative complications and hospital stay in Group B. The p-value was significant in Group B patients <0.05(0.007). There were 6 deaths, all of them had severe form of peritonitis with massive contamination and delayed presentation to the hospital. This study also revealed that men are commonly affected and duodenal ulcer perforation is the commonest site of perforation. Escherichia coli is the most common organism isolated. CONCLUSION: In our study peritonitis is more common in men compared to women. The most common age group is in between 21 – 40 years in cases of peritonitis with the mean age of 37 years. Duodenal ulcer perforation is the commonest site of perforation. Escherichia coli is the most common organism isolated in the peritoneal fluid. Use of with usage of three antimicrobials, Ceftriaxone, Metronidazole and Amikacin(p<0.05) is beneficial in reduction in postoperative complications and hospital stay when compared to usage of two antimicrobials, Ceftriaxone and Metronidazole which is statistically significant.

Study of Incidence of Peptic Ulcer Perforation in Young Adults: A Hospital Based Study

Background: Peptic ulcer formation affects about 2-10% of world population every year with higher incidence in younger individuals. Being a surgical emergency, it has higher mortality and morbidity. Thus, the aim of our study was to evaluate the incidence of peptic ulcer perforation based on gender, age and also to study its associated risk factors, clinical presentations, site along with surgical management and complications. Materials & Methods: 75 patients diagnosed with perforated peptic ulcer were included and this study was conducted in the department of Surgery Government Bangur Hospital, Pali, Rajasthan, India. Structured performa was prepared to obtained details of patients and ethical clearance from the institute was also taken prior to the study. Results: 76% of patients in our study were males and 24% were females with male and female ratio 1:3.16. The prevalence of perforation was high in age group 20-30 years (30.7%). 62.7% of cases had positive family history and the incidence was in the patients who consumed non-vegetarian (84.8%), spicy (61.4%) and oily (69.5%) foods. Frequently observed clinical presentation were abdominal pain followed by tenderness and rigidity and gas under diaphragm. The common site of perforation was duodenum (62.7%) and most of the cases were treated by closure with omental patch (81.3%). The post-surgical complications frequently observed were wound infection (30.6%) and chest infection (28%). Conclusion: Peptic ulcer perforation is common disorder of gastrointestinal tract, now affecting younger adults with male preponderance. It is associated with unwanted health and economic issues. Therefore, earlier management is only the way to minimize complications and mortality.

Management Outcomes of Colonoscopic Perforations Are Affected by the General Condition of the Patients.

PurposeThe management of a colonoscopic perforation (CP) varies from conservative to surgical. The objective of this study was to evaluate the outcomes between surgical and conservative treatment of patients with a CP.MethodsFrom 2003 to 2016, the medical records of patients with CP were retrospectively reviewed. Patients were divided into 2 groups depending on whether they initially received conservative or surgical treatment.ResultsDuring the study period, a total of 48 patients with a CP were treated. Among them, 5 patients had underlying colorectal cancer and underwent emergency radical cancer surgery; these patients were excluded. The mean age of the remaining 43 patients was 64.5 years old, and the most common perforation site was the sigmoid colon (15 patients). The initial conservative care group included 16 patients, and the surgery group included 27 patients. In the conservative group, 5 patients required conversion to surgery (failure rate: 5 of 16 [31.3%]). Of the surgery group, laparoscopic surgery was performed on 19 patients and open surgery on 8 patients, including 2 conversion cases. Major postoperative complications developed in 11 patients (34.4%), and postoperative mortality developed in 4 patients (12.5%). The only predictor for poor prognosis after surgery was a high American Society of Anesthesiologists physical status classification.ConclusionIn this study, conservative treatment for patients with a CP had a relatively high failure rate. Furthermore, surgical treatment showed significant rates of complications and mortality, which depended on the general status of the patients.

Type II perforation of the body of the gallbladder in acalculous cholecystitis: a rare complication of enteric fever

Gallbladder perforation is a rare but potentially life-threatening complication of acute cholecystitis with or without gallstones. Enteric fever leading to small bowel perforation is rare, and gallbladder perforation is extremely rare. It requires early and accurate diagnosis. If left untreated, it is associated with high mortality. Clinical diagnosis is often difficult. The most common site of perforation is the fundus; perforation in the body is rare. We report a case of gallbladder perforation as a complication of enteric fever, which presented as acute abdomen and responded very well after cholecystectomy. Although rare and unusual, this case report shows that gallbladder perforation should be considered in patients presenting with acute abdomen and a history of enteric fever.Keywords: Enteric fever; Acalculous cholecystitis; Perforation; Cholecystectomy

Incidence of Suboptimal Applicator Placement and the Resulting Dosimetric Impact in Image-Based Intracavitary Brachytherapy.

Aim:With the advent of computed tomography (CT)-based brachytherapy, it is possible to view the appropriate placement of the applicator within the uterine canal and detect uterine perforation. In this study, the incidence of suboptimal placement of the intracavitary applicator and the resulting dosimetric impact were analyzed and compared with a similar set of ideal applicator placement.Materials and Methods:CT datasets of 282 (141 patients) high dose rate brachytherapy insertions between January and April 2016 were analyzed. The target volumes and organs at risk (OAR) were contoured as per the Groupe Européen de Curiethérapie European Society of Therapeutic Radiation Oncology guidelines. The position of the applicator in the uterine cavity was analyzed for each application.Results:The suboptimal insertion rate was 11.7%. There were 26 perforations and 7 subserosal insertions. The most common site of perforation was through the posterior wall of the uterus (42.4%). Fundus perforation and anterior wall perforation were seen in 24.2% and 12.1% of patients, respectively. The average dose to 90% of the target volume (D90 to high-risk clinical target volume) was the highest (9.15 Gy) with fundal perforation. Average dose to 2 cc (D2cc) bladder was highest for fundus perforation (7.65 Gy). The average dose received by 2 cc of rectum (D2cc) was highest (4.49 Gy) with posterior wall perforation. The average D2cc of the sigmoid was highest with anterior perforation (3.18 Gy).Conclusion:In order to achieve better local control and to decrease doses to OAR, it is important to perform a technically accurate applicator placement. A cost-effective, real-time image guidance modality like ultrasound is recommended for all insertions to ensure optimal applicator insertion.

Perforation of myocardial wall and great vessels after cardiovascular interventions-a 5-year analysis.

Less invasive procedures have replaced open surgical treatment in many cardiovascular disorders. During these interventions, iatrogenic cardiac perforation may ensue, which is a severe complication and requires immediate diagnostic assessment and treatment. From March 2011 to April 2016, all patients referred to the Dept. of Cardio-thoracic Surgery with the diagnosis of iatrogenic perforation of myocardial wall or great vessels were included into the retrospective study. Complications during transapical transcutaneous aortic valve replacements (TAVR) procedures and percutaneous coronary intervention (PCI) were excluded from analysis. Symptoms, therapeutic strategy, intraoperative findings, and outcome were evaluated. Forty-four patients suffered from myocardial wall or vessel perforation. Most common site of perforation were right (n=26; 59.1%) and left (n=8; 18.2%) ventricle. Other structures were involved in ten cases (22.7%). Open surgical treatment was required in 27 cases (61.4%). Mortality after left and right ventricular laceration was 75.0% and 11.5%, respectively. Most common cause of death was cardiocirculatory failure (n=5). Iatrogenic perforation of myocardial wall or central vessels during percutaneous interventional procedures is a rare but life-threatening complication. Despite immediate treatment efforts, mortality is high, particularly after left ventricular laceration.

Idiopathic Perforation of the Sigmoid Colon in a 2.5 Years Old Girl: A Case Report

Idiopathic colon perforation is rare in children. It is more common at the extremes of age. Splenic flextures, ileocecal and lower sigmoid regions are the most common sites of perforation. Delay in proper management of this condition is associated with high mortality and morbidity rate. We report on the case of a 2.5 years old girl who presented with fever, diarrhea, nausea and vomiting and progressive abdominal distention.Finally, she underwent an exploratory laparotomy for suspected peritonitis because of the patient's worsening condition. An area of perforation was found in the sigmoid colon that segmental resection and an end double barrel colostomy was done.

Acute Spontaneous Multiple Ileal Tuberculosis Perforation: A Case Report

A 18 years old boy presented with severe diffuse abdominal pain, constipation, abdominal distention, fever and diagnosed as a case of perforation as free gas noted under both dome of the diaphragm. After resuscitation, exploratory laparotomy was done and diagnosed as a case of multiple spontaneous leaky perforations of jejunum and ileum 25 to 30 cm from duodeno-Jejunal flexure (DJ) up to terminal ileum. Peritoneal toileting and excisional biopsy of the mesenteric lymph node were done. Operative and postoperative period were uneventful. Histopathological examination of the resected lymph node revealed granulomatous inflammation compatible with tuberculosis. Anti-tubercular therapy was started and continued for 6 months. Patient was discharged on the 12th postoperative day in a good condition. At 3 months of follow up the patient was asymptomatic and thriving well. Free perforation is one of the most feared complications of the intestinal tuberculosis. The terminal ileum is the most common site of perforation, while the majority of (90%) perforations are solitary. Bangladesh Journal of Infectious Diseases 2016;3(2):52-54

Acute peritonitis secondary to hollow viscous perforation: a clinical study

Background: Peritonitis due to hollow visceral perforation is commonly encountered in surgical practice it is defined as inflammation of the serosal membrane that lines the abdominal cavity and the organs contained therein. The objective of this study was to study the frequency of peritonitis secondary to hollow viscous perforation and complications of operative management.Methods: 50 cases were studied with peritonitis due to hollow viscous perforation as surgical emergencies underwent emergency laparotomy, details of age, sex, anatomical location, signs and symptoms, reliability of investigation like X-ray-abdomen, complications, mortality were noted.Results: The most common age group affected is 50 years and above. Duodenum (52%) is the most common site of perforation followed by ileal perforation (26%) appendicular (14%) and colonic perforation (4%). 84% of the patients were male patients and 16% of the patients were females. Duodenal ulcer (52%) is the most common cause of perforative peritonitis followed by small intestinal perforation. The appendicular perforation forms the next commonest cause of perforation (14%). Guarding and rigidity was present in 90% of patients. Diagnosis is made clinically and confirmed by presence of pneumoperitoneum (76%) on radiographs. Laparotomy with closure of the perforation with omental patch (64%) is the commonest operative management for perforated peptic ulcer fallowed by simple closure, resection and anastomosis, and loop ileostomy. The most common postoperative complication observed was lower respiratory tract infection. Overall mortality rate was 8%. The average duration of stay in hospital is 12.44 days.Conclusions: Laparotomy with closure of the perforation with omental patch closure is the commonest method of surgical management in perforative peritonitis due to hollow viscous perforation.

Clinical profile in cases of intestinal perforation

Background: Intestinal perforation is a surgical emergency with a wide variety of clinical features and causes. Regional variations are common with regards to the cause of intestinal perforation, and need to be evaluated in local settings. The study was conducted to determine the clinical profile of patients with intestinal perforation, with regard to clinical presentation, investigative results, pathological features, surgical findings, complications and outcome.Methods: Detailed information was recorded on 40 cases of intestinal perforation with regard to clinical features, investigative results, surgical findings, post-operative course and outcome. The data was analysed with appropriate statistical methods.Results: The site of perforation was gastric 27.5%, duodenum 20%, jejunum 5%, ileum 35%, appendix 10% and colon 2.5%. Main causes included peptic ulcer 42.5%, typhoid 25% and few cases of trauma, tuberculosis, appendicitis and malignancy. Peritonitis was universal. Primary repair, resection with anastomosis, appendectomy and stoma were the operative procedures. Morbidity rate was 60.0% and mortality rate was 12.5%.Conclusions: Commonest site of perforation was gastro-duodenal while commonest cause was peptic ulcer disease. Morbidity and mortality was comparable with other studies.