Differences In Perforation Rates Research Articles

Reduction in CT scan number with the reference frame middle attachment method in intraoperative CT navigation for adolescent idiopathic scoliosis.

Elucidate whether it is preferable to use the reference frame (RF) middle attachment (RFMA) method over the edge of the planned pedicle screw (PS) insertion area for RF placement in the surgery for adolescent idiopathic scoliosis (AIS) with intraoperative computed tomography (CT) navigation. Eighty-six consecutive patients (76 female and 10 male; mean age: 15.9years) with AIS who underwent posterior spinal fusion using intraoperative CT navigation were enrolled. The group with the RF placed at the most distal part of the CT scan range was defined as the distal group (Group D), with other placements classified into the middle group (Group M). PS perforation rate and surgical outcome were compared between the groups. There was no significant difference in perforation rate between Group M and Group D (3.4% vs. 3.0%, P = 0.754). The mean ± standard deviation number of instrumented vertebrae at the first CT scan was significantly higher in Group M (8.2 ± 1.2 vs. 6.3 ± 1.2, P < 0.001), while mean blood loss was significantly lower (266 ± 185mL vs. 416 ± 348mL, P = 0.011). The frequency of needing a second CT scan for PS insertion was significantly lower in Group M (38% vs. 69%, P = 0.04). The RFMA method in thoracic scoliosis surgery for AIS with intraoperative CT navigation could significantly decrease the number of CT scans and blood loss while maintaining a comparable PS perforation rate to RF placement at the distal end of the planned PS insertion range.

The costs and benefits of emergent surgical workflow for acute appendicitis in children

BackgroundControversy exists regarding how operative timing affects patient safety and resource utilization for acute appendicitis. Over 3 years, our institution trialed efforts to optimize appendectomy workflow. Our aim is to describe the ramifications of expediting appendectomy and implementing standardized protocols relative to historic controls. MethodsPatient records at a freestanding children's hospital were reviewed from synchronized 6-month periods from 2019 to 2021. During Year 1 (historic), no standardized workflows existed. In Year 2 (expedited), appendicitis management was protocoled using a clinical quality improvement bundle, which included performing appendectomies within two hours of diagnosis. In Year 3 (QI), operative timing was relaxed to the same calendar day while all prior QI initiatives continued. Descriptive statistics were performed, using hospital length of stay (LOS) as the primary outcome. Results298 patients underwent appendectomy for acute appendicitis. The median expedited workflow LOS was 15.3 hours shorter (p = 0.003) than historic controls; however, this was sustained despite relaxation of surgical urgency in the QI workflow. No differences in perforation rates were observed. During the expedited workflow, OR overtime staffing expense increased by $90,000 with no significant change in hospital costs. In multivariate regression, perforation was the only variable associated with LOS. ConclusionHospital LOS can be shortened by expediting appendectomy. However, in our institution this did not decrease hospital costs and was furthermore balanced by higher personnel expenses. A sustained decrease in LOS after relaxing operative urgency standards implies that concurrent QI initiatives represent a more effective and cost-efficient strategy to decrease hospital resource utilization. Level of evidenceLevel III

A Systematic Review and Meta-Analysis: Timing of Elective Removal of Tympanostomy Tubes.

Tympanostomy tube (TT) placement is the most common surgical procedure in children. Less than 10% of TT do not self-extrude. This study is a systematic review (SR) on elective TT removal in the pediatric population: timing, perforation rates, and role of simultaneous repair. A PICOTS (population, intervention, comparison, outcome, timing, setting) question was formulated: In pediatric patients who have retained TT, what is the preferred time to elective removal of such tubes, and what are the outcomes in terms of perforation rates? Does an intervention at the time of TT removal improve perforation rates? Systematic review and meta-analysis. We searched four major electronic databases: EMBASE, MEDLINE, CDSR, CCRCT for articles published prior to 02/19/20. EndNote® was used to gather references, review abstracts, and obtain full text articles. Inclusion criteria were studies reporting patients aged 0 to 18 years undergoing elective TT removal with follow-up greater than 3 months. Exclusion criteria included patients >18 years, duplicate patient series, or case series with fewer than five patients. Articles that were not available in English, not available in full text, and those that only addressed long-acting TT were excluded. Data were pooled and meta-analysis was conducted to examine how timing of TT removal, patching of the tympanic membrane, or any TM intervention at TT removal affected outcomes. A total of 1,064 references were found. We identified 63 unique studies for full text review. Of these, 17 were selected for SR. MINORS (Methodological Index for Nonrandomized Studies) scores were low-revealing high bias among the studies. Reported perforation rates after elective TT removal ranged from 0% to 57%. Four studies had data suitable for comparative meta-analysis, which showed a significant increase in perforation rates after elective removal of TT after 3 years compared to removal prior to 3 years (OR 2.89; CI 1.78-4.69). No difference in perforation rates were identified when TM intervention vs. no intervention at time of TT removal was performed (six studies: OR 1.21; CI 0.71-2.07). No difference in perforation rates was identified when the type of TM intervention was compared, including freshening of TM edges, to patching with various materials (paper, fat, gelfoam®/gelfilm®, Trichloroacetic acid) (three studies: OR 1.07; CI 0.52-2.19). From the data reviewed in this SR and meta-analysis, elective TT removal at or prior to 3 years' retention showed decreased perforation rates. However, TM intervention at the time of TT removal was not shown to lower perforation rates. In the absence of tube complications such as granuloma formation, nonfunctional tube, or chronic tube otorrhea, it may be reasonable to wait up to 3 years to electively remove a retained TT. Laryngoscope, 132:2063-2070, 2022.

Controversies of colonic stenting in obstructive left colorectal cancer: a critical analysis with meta-analysis and meta-regression.

After almost three decades since the first description of colonic stents, the controversies of its safe application continue to impede the readiness of adoption by clinicians for malignant left bowel obstruction. This review seeks to address some of the controversial aspects of stenting and its impact on surgical and oncological outcomes. Medline, Embase, and CNKI were searched for articles employing SEMS for left colonic obstruction. Outcomes analyzed include success rates, complications, and long-term survival. Pooled risk ratio (RR) and 95% confidence interval (CI) were estimated. 36 studies were included with 2002 patients across seven randomized controlled trials and 29 observational studies. High technical (92%) and clinical (82%) success rates, and low rates of complications, including perforation (5%), were found. Those with > 8% perforation rates had poorer technical success rates than those with ≤ 8%, but there were no significant differences in 90-day in-hospital mortality and three and 5-year overall and disease-free survival. A significant increase was found in technical (RR = 1.094; CI, 1.041-1.149; p < 0.001) and clinical (RR = 1.158; CI, 1.064-1.259; p = 0.001) success rates when the duration between stenting and surgery was ≥ 2weeks compared to < 2weeks, but there were no significant differences in perforation rates, 90-day in-hospital mortality, and long-term survival. Colonic stenting is safe and effective with high success rates and low complication rates. However, outcomes of higher perforation rates and optimal timing from stent till surgery remain unclear, with only a few studies reporting on these outcomes, leaving areas for future research.

Ultrasound-guided hydrostatic reduction versus fluoroscopy-guided air reduction for pediatric intussusception: a multi-center, prospective, cohort study

BackgroundIntussusception is the most common abdominal emergency in children. The first line treatment of uncomplicated pediatric intussusception is enema reduction. Until now, there have been no multi-center studies comparing the effectiveness and safety of UGHR and FGAR in the treatment of pediatric intussusception. The aim of this study was to compare the effectiveness and safety of the two most commonly used enema methods of pediatric intussusception: ultrasound-guided hydrostatic reduction (UGHR) and fluoroscopy-guided air reduction (FGAR).MethodsFrom November 1, 2017 to October 31, 2018, we conducted a multi-center, prospective, cohort study. Children diagnosed with intussusception in four large Children’s Medical Centers in China were divided into UGHR and FGAR groups. Stratified analysis and subgroup analysis were used for further comparison. The success and recurrence rates were used to evaluate the effectiveness of enema reduction. The perforation rate was used to evaluate the safety of enema reduction.ResultsA total of 2124 cases met the inclusion criteria (UGHR group: 1119 cases; FGAR group: 1005 cases). The success and recurrence rates in the UGHR group were higher than in the FGAR group (95.80%, 9.28% vs. 93.13%, 10.65%) (P < 0.05, P > 0.05), respectively. The perforation rate in the UGHR group was 0.36% compared with 0.30% in the FGAR group (P > 0.05). Subgroup analysis showed the success rates in the UGHR group were higher than in the FGAR group of patients with onset time between 12 and 24 h (95.56% vs. 90.57%) (P < 0.05). Of patients aged 4 to 24 months, the success rates in the UGHR group were also higher than in the FGAR group (95.77% vs. 91.60%) (P < 0.05). Stratified analysis showed the success rates in the UGHR group were higher than in the FGAR group in patients with the symptom of bloody stool (91.91% vs 85.38%) (P < 0.05).ConclusionsUGHR and FGAR are safe, nonsurgical treatment methods for acute pediatric intussusception. UGHR is superior to FGAR, no radiation risk, its success rate is higher, without a difference in perforation rate, especially for patients aged 4–24 months.Level of evidenceLevel II.

Efficacy of surgical or endoscopic treatment of idiopathic achalasia: a systematic review and network meta-analysis

Treatment of achalasia has changed substantially over the past 20 years. Therapeutic options offered to patients vary, depending on access to both resources and expertise, and include pneumatic dilation (PD), laparoscopic Heller's myotomy (LHM), or per-oral endoscopic myotomy (POEM). Although there are head-to-head trials of these interventions, many of these are small and underpowered, so relative efficacy is unknown. We did a systematic review and network meta-analysis to try to resolve this uncertainty. We searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, and Embase Classic from database inception up to June 11, 2020, for randomised controlled trials (RCTs) assessing the efficacy of POEM, LHM, or PD, compared with each other in adults with idiopathic achalasia. We extracted all data as dichotomous outcomes (treatment success or failure) after completion of therapy. We also extracted country of origin, number of centres, duration of follow-up, and primary outcome measure used to define treatment success or failure. Data were extracted for intention-to-treat analyses, with all dropouts assumed to be treatment failures (ie, symptomatic at final point of follow-up), wherever trial reporting allowed this. We pooled data using a random effects model, and assessed heterogeneity between studies using the I2 statistic. Risk of bias was examined for all studies. The primary outcome was efficacy, in terms of a dichotomous measure of treatment success or failure, after a minimum of 1 year of follow-up. Secondary outcomes were occurrence of perforation, adverse events, serious adverse events (including death), need for reintervention, need for surgery as a result of complications, development of gastro-oesophageal reflux, or erosive oesophagitis. Efficacy was reported as a pooled relative risk (RR) of treatment failure, with a 95% CI, for each comparison tested, and ranked by therapy according to P-score. Of 1044 studies initially assessed, nine were eligible RCTs, which comprised 911 participants in total. None of the nine studies were at low risk of bias. Of the 911 participants 372 (41%) participants were randomly assigned to LHM, 317 (35%) participants to PD, and 222 (24%) participants to POEM. Of the three strategies, POEM was ranked first (RR of failure of treatment 0·33, 95% CI 0·15-0·71; P-score 0·89), then LHM (RR 0·45, 0·26-0·78, P-score 0·61). There was moderate heterogeneity between studies (I2=61·5%). Both POEM and LHM were superior to PD on direct and indirect comparison, but neither was significantly more effective than the other. There were no significant differences in perforation rates, need for re-intervention or surgery, gastro-oesophageal reflux, erosive oesophagitis, or serious adverse events, but PD was less likely to lead to adverse events than POEM. POEM and LHM should be the preferred treatments for idiopathic achalasia. PD performed worst in terms of treatment success, and therefore its role in the management of patients with achalasia is less certain. None.

Increase in Pediatric Perforated Appendicitis in the New York City Metropolitan Region at the Epicenter of the COVID-19 Outbreak.

Objective:The aim of the study was to determine whether perforated appendicitis rates in children were influenced by the Coronavirus disease 2019 (COVID-19) surge.Background:Disruption of care pathways during a public health crisis may prevent children from obtaining prompt assessment for surgical conditions. Progression of appendicitis to perforation is influenced by timeliness of presentation. In the context of state-mandated controls and public wariness of hospitals, we investigated the impact of the COVID-19 outbreak on perforated appendicitis in children.Study Design:We conducted an analysis of all children presenting to 3 hospital sites with acute appendicitis between March 1 and May 7, 2020, corresponding with the peak COVID-19 outbreak in the New York City region. Control variables were collected from the same institutions for the preceding 5 years. The primary outcome measure was appendiceal perforation.Results:Fifty-five children presented with acute appendicitis over 10 weeks. Compared to a 5-year control cohort of 1291 patients, we observed a higher perforation rate (45% vs 27%, odds ratio 2.23, 95% confidence interval 1.29–3.85, P = 0.005) and longer mean duration of symptoms in children with perforations (71 ± 39 vs 47 ± 27 h, P = 0.001) during the COVID-19 period. There were no differences in perforation rates (55% vs 59%, P = 0.99) or median length of stay (1.0 vs 3.0 days, P = 0.58) among children screening positive or negative for SARS-CoV-2.Conclusions:Children in the epicenter of the COVID-19 outbreak demonstrated higher rates of perforated appendicitis compared to historical controls. Preoperative detection of SARS-CoV-2 was not associated with inferior outcomes. Although children likely avoid much of the morbidity directly linked to COVID-19, disruption to local healthcare delivery systems may negatively impact other aspects of pediatric surgical disease.

Association Between the Frequency of Glove Change and the Risk of Blood and Body Fluid Exposure in Gastrointestinal Surgery.

Surgical gloves are used to prevent the transmission of microorganisms from the surgeon's hands to the patient and vice versa. Little is known on the optimal frequency of glove changing. Therefore, we aimed to examine the optimal frequency of glove change during surgery by assessing the glove perforation rate in gastrointestinal surgery. In this observational prospective cohort study, we investigated the incidence of perforation of 5,267 gloves during gastrointestinal surgeries. The overall glove perforation rate was 10.1%. There was no significant difference between single gloving (10.2%) and double gloving (10.0%; p = 0.8491). However, the perforation rate of the inner glove (5.7%) was found to be significantly lower than that of the outer glove (11.6%) (p < 0.0001). A significant difference in perforation rate was observed after wearing inner gloves for 240min (< 240min, 4.4%; ≤ 240min, 7.2%; p = 0.0314), and outer gloves for 60min (< 60min, 7.1%; ≤ 60min, 12.6%; p < 0.0001). We found cumulative perforation rate to rapidly increase until the wear time was 90min. The inner gloves and outer gloves have a higher perforation rate as the wear time increased. To reduce the risk of intraoperative blood and fluid exposure and prevent healthcare-associated infection, gloves should be changed for approximately every 60-90min for outer gloves and approximately every 240min for inner gloves.

Greenfield stainless steel vena cava filters on computed tomography follow-up

ObjectiveThe objective of this study was to evaluate complications of Greenfield (Boston Scientific, Marlborough, Mass) stainless steel inferior vena cava (IVC) filters on follow-up computed tomography (CT) imaging and to elucidate associated risk factors. MethodsNinety-three patients with CT studies obtained for other reasons after Greenfield IVC filter placement (2007-2014) were retrospectively studied. Greenfield filters were placed permanently in those with venous thromboembolism and an expected lifelong contraindication to anticoagulation or life expectancy <6 months. Patients' demographic data, procedural characteristics, and imaging studies were reviewed and factors associated with perforation rates were analyzed. ResultsA total of 190 follow-up CT imaging studies were available for review. In total, filter-associated IVC thrombus (n = 10 [10.7%]) and pulmonary embolism breakthrough (n = 4 [4.3%)] were documented by contrast-enhanced CT. Perforation was evident in 18 patients (19.4%) with an average indwelling time of 256 days. No symptomatic perforation and no strut fracture were documented. There was no significant difference in perforation rate with respect to age of the patient (P = .61), sex (P = 1.00), or history of malignant disease (P = .40). The filter perforation rate and number of perforating struts were significantly higher in patients with longer indwelling time (>90 days) than in patients with shorter indwelling time (<90 days; P < .01). Caval cross-sectional areas of patients who experienced IVC filter perforations at >90 days were significantly smaller than those of nonperforated patients (284 vs 358 mm2; P < .01). ConclusionsStainless steel Greenfield filters remain a relatively safe option for patients requiring permanent mechanical filtration.

Difference in perforation rates of jetting tool nozzles and influencing factors

Variations in the rates of hydraulic perforation among different jetting nozzles are common in gas well development, especially the multi-stage perforation of horizontal wells. A laboratory experiment was conducted to analyse the effects of flow rate, liquid viscosity and particle size on the perforation rate of a multi-nozzle structure under liquid-solid flow. The spatial distributions of particles and sample erosion rates were documented for multi-stage multi-angle nozzles with a variable difference in liquid properties and flow parameters using three particle sizes. Results showed that the difference in perforation rates among the nozzles was affected by the particle distribution inside the jetting tool and the energy of the particles ejected by each nozzle. Furthermore, the difference in perforation rates of nozzles with different jet angles was markedly affected by particle size, then by the flow rate and finally the liquid viscosity. [Received: April 15, 2018; Accepted: May 28, 2018]

Does sinus membrane thickness influence the risk of perforation during lateral sinus lift surgery for dental implants? a systematic review and meta-analysis.

We reviewed the literature to examine if the thickness of the sinus membrane is a risk factor for perforation during lateral sinus lift surgery. We searched Embase, PubMed, and Web of Science databases till 4th December 2023 for studies examining the risk of perforation with different sinus membrane thicknesses. Studies reporting sinus membrane thickness in perforation and non-perforation cases were also included. Eleven studies were eligible. All studies used cone beam computed tomography for measuring sinus membrane thickness. Meta-analysis showed that sinus membrane thickness was significantly lower in perforation cases as compared to non-perforation cases (MD: -0.91 95% CI: -1.48, -0.33 I2=94%). Four studies used 2mm as the cut-off to define thick and thin sinus membranes. Pooled analysis failed to demonstrate any significant difference in perforation rates (OR: 0.97 95% CI: 0.44, 2.17 I2=56%). Meta-analysis of studies using 1.5mm (OR: 0.66 95% CI: 0.29, 1.48 I2=72%) and 1mm cut-off (OR: 0.93 95% CI: 0.34, 2.56) also demonstrated similar non-significant results. Our study shows that the sinus membrane is significantly thinner in cases with perforations as compared to those with no perforations. However, a meta-analysis based on different membrane thickness cut-offs failed to demonstrate a relationship between thinner sinus membranes and a higher risk of perforation. There is a need for further studies examining the role of sinus membrane thickness on perforation rates.

Difference in perforation rates of jetting tool nozzles and influencing factors

Difference in perforation rates of jetting tool nozzles and influencing factors

Incidence of Glove Perforation During Hand Surgical Procedures

To determine the rate of glove perforation during hand surgery. We prospectively examined the rate of glove perforations among 10 fellowship-trained hand surgeons at our institution during a 6 week period. Gloves were tested for perforation using a water-fill technique at the conclusion of each surgical procedure. Surgeons recorded the presence of any glove perforations. Eleven perforations were identified in 10 gloves among 600 surgical procedures during the study period. The perforation rate per case was 1.5% (95% confidence interval, 0.78% to 2.8%). Forty percent of perforations (n= 4) occurred during fracture surgery. Other holes occurred during isolated carpal tunnel release (n= 3) or combined carpal tunnel and trigger finger release (n= 3). The perforation was noticed intraoperatively in only 2 gloves. The difference in perforation rate between single- and double-gloved procedures was not significant. There were no perforations in the inner glove of surgeons who double gloved. A total of 73% of holes (8 of 11) occurred on surgeons' index finger; 75% of these were on the dominant hand. The dominant thumb, non-dominant ring and nondominant little fingers each had a single perforation. The rate of glove perforation during hand surgery is low. Holes can occur even during soft tissue procedures of short duration. The dominant index finger appears to be at greatest risk for perforation. When they do occur, most often holes are not noticed by the operating surgeon. The baseline glove perforation rate is unknown. A high level of vigilance is required to maintain sterile technique.

Evaluating the risk of appendiceal perforation when using ultrasound as the initial diagnostic imaging modality in children with suspected appendicitis.

Ultrasound scan has gained attention for diagnosing appendicitis due to its avoidance of ionizing radiation. However, studies show that ultrasound scan carries inferior sensitivity to computed tomography scan. A non-diagnostic ultrasound scan could increase the time to diagnosis and appendicectomy, particularly if follow-up computed tomography scan is needed. Some studies suggest that delaying appendicectomy increases the risk of perforation. To investigate the risk of appendiceal perforation when using ultrasound scan as the initial diagnostic imaging modality in children with suspected appendicitis. We retrospectively reviewed 1411 charts of children ≤17 years old diagnosed with appendicitis at two urban academic medical centers. Patients who underwent ultrasound scan first were compared to those who underwent computed tomography scan first. In the sub-group analysis, patients who only received ultrasound scan were compared to those who received initial ultrasound scan followed by computed tomography scan. Main outcome measures were appendiceal perforation rate and time from triage to appendicectomy. In 720 children eligible for analysis, there was no significant difference in perforation rate between those who had initial ultrasound scan and those who had initial computed tomography scan (7.3% vs. 8.9%, p = 0.44), nor in those who had ultrasound scan only and those who had initial ultrasound scan followed by computed tomography scan (8.0% vs. 5.6%, p = 0.42). Those patients who had ultrasound scan first had a shorter triage-to-incision time than those who had computed tomography scan first (9.2 (IQR: 5.9, 14.0) vs. 10.2 (IQR: 7.3, 14.3) hours, p = 0.03), whereas those who had ultrasound scan followed by computed tomography scan took longer than those who had ultrasound scan only (7.8 (IQR: 5.3, 11.6) vs. 15.1 (IQR: 10.6, 20.6), p < 0.001). Children < 12 years old receiving ultrasound scan first had lower perforation rate (p = 0.01) and shorter triage-to-incision time (p = 0.003). Children with suspected appendicitis receiving ultrasound scan as the initial diagnostic imaging modality do not have increased risk of perforation compared to those receiving computed tomography scan first. We recommend that children <12 years of age receive ultrasound scan first.

Clipping prevents perforation in large, flat polyps.

AIMTo determine if prophylactic clipping of post-polypectomy endoscopic mucosal resection (EMR) mucosal defects of large, flat, right sided polyps prevents perforations.METHODSIRB approved review of all colonoscopies, and prospective data collection of grasp and snare EMR performed by 2 endoscopists between January 1, 2010 and March 31, 2014 in a community ambulatory endoscopy center. The study consisted of two phases. In the first phase, all right-sided, flat polyps greater than or equal to 1.2 cm in size were removed using the grasp and snare technique. Clipping was done at the discretion of the endoscopist. In the second phase, all mucosal defects were closed using resolution clips. Phase 2 of the study was powered to detect a statistically significant difference in perforation rate with 148 EMRs, if less than or equal to 2 perforations occurred.RESULTSIn phase 1 of the study, 2121 colonoscopies were performed. Seventy-five patients had 95 large polyps removed. There were 4 perforations in 95 polypectomies (4.2%). The perforations occurred in polyps ranging in size from 1.5 cm to 2.5 cm. In phase 2, there were 2464 colonoscopies performed. One hundred and sixteen patients had 151 large polyps removed, and all mucosal defects were clipped. There were no perforations (P = 0.0016). There were no post-polypectomy hemorrhages in either phase. An average of 2.15 clips were required to close the mucosal defects. The median time to perform the polypectomy and clipping was 13 min, and the median procedure duration was 40 min. Five percent of all patients undergoing colonoscopy in our community based, ambulatory endoscopy center had flat, right sided polyps greater than or equal to 1.2 cm in size.CONCLUSIONProphylactic clipping of the mucosal resection defect of large, right-sided, flat polyps reduces the incidence of perforation.

Safety of Hip Anchor Insertion From the Midanterior and Distal Anterolateral Portals With a Straight Drill Guide: A Cadaveric Study

Background: During arthroscopic labral refixation, suture anchors are typically inserted from either the midanterior (MA) portal or the distal anterolateral (DALA) portal; however, no studies have previously compared these techniques. Purpose/Hypothesis: The purpose of this study was to compare acetabular rim accessibility and associated complication rates of anchor insertion from these portals. We hypothesized that rim access would be better from the DALA portal. Additionally, we hypothesized that articular surface perforation would occur more commonly from the MA portal while psoas tunnel perforation would occur more commonly from the DALA portal. Study Design: Controlled laboratory study. Methods: Sixteen pelvic cadaveric specimens (32 hips) were obtained and arthroscopic surgery performed in the supine position. Suture anchors were placed at 7 predetermined locations (9-, 11-, 12-, 1-, 2-, 3-, and 4-o’clock positions). Hips were treated as matched pairs, such that one hip from each specimen had all anchors placed from the MA portal and the other from the DALA portal. Allocation ensured an equal distribution of laterality between groups. After anchor insertion, specimens underwent computed tomography and dissection for further evaluation. Results: Rim accessibility was similar between the groups; anchor insertion was most difficult at the 9-o’clock position, particularly with the MA portal technique, where only 50% (8/16) of attempts were successful, in comparison to the DALA portal technique, where 75% (12/16) of attempts were successful. Additionally, the 4-o’clock position proved challenging to access with the DALA portal technique, where only 75% (12/16) of attempts were successful, compared with 100% with the MA portal technique. The difference in accessibility of these techniques, however, did not reach statistical significance at the 9-o’clock position (P = .2734) or 4-o’clock position (P = .1012). Articular surface perforation occurred in 4.48% of all anchor insertion attempts, most commonly at the 3-o’clock position (P = .0242). From the MA portal, 4.00% (4/100) perforated the joint, compared with 4.95% (5/101) from the DALA portal (P > .999). Further, there were no significant differences in perforation rates at each location between the techniques (P > .999). Psoas tunnel perforation occurred in 7.69% of all anchor insertion attempts between 2 and 4 o’clock, with equal rates at each location (P ≥ .6606). From the MA portal, 4.17% (2/48) perforated the psoas tunnel, compared with 11.63% (5/43) from the DALA portal (P ≥ .2486). Further, there were no significant differences at each location between the techniques (P ≥ .4839). There was no association between acetabular version, femoral version, or lateral center-edge angle (LCEA) and articular surface or psoas tunnel perforation, regardless of portal use. Conclusion: Anchor insertion from either the MA or DALA portal appears to confer similar rim access and rates of articular surface or psoas tunnel perforation, with a cumulative rate of 4.48% and 7.69%, respectively. Rates of perforation did not differ between the portals and were not associated with acetabular or femoral version or LCEA. Clinical Relevance: Caution should be employed when inserting anchors for labral refixation, particularly in anterior and medial locations (2-4 o’clock), as articular surface and psoas tunnel perforation may occur at a rate higher than previously anticipated. Portal selection does not appear to influence these outcomes.

Effects of Timing to Diagnosis and Appendectomy in Pediatric Appendicitis.

Prospectively follow pediatric appendicitis patients to assess outcomes and rates of appendiceal perforations relative to duration of symptomatology and appendectomy timing. Data were collected on the duration of symptomatology to diagnosis and from diagnosis to appendectomy. Symptomatology duration was evaluated in 24-hour increments, and diagnosis to appendectomy was evaluated in 3-hour intervals. Appendiceal perforation rates, hospital length of stay (LOS), and operating room (OR) times were evaluated. Data were analyzed on 230 patients. Average age was 9.3 years (±3.2), 93 (40%) were female, and 64 (28%) appendectomies were perforated. Perforations had a mean 10 minutes longer OR time (63 vs 50 minutes, P < 0.001) and a 57% increase in hospital LOS (3 days' interquartile range, 1-5 vs 1 day's interquartile range, 1-3; P < 0.001). From diagnosis to appendectomy, those taken 0 to 3 hours, 4 to 6 hours, or longer than 6 hours after diagnosis had no statistically significant difference in hospital LOS or perforation rates and no clinically significant difference in OR times. Symptomatology greater than 48 hours had hospital LOS 55.7% greater and 4.9 times increased odds for perforation than those 0 to 23 hours (P < 0.05).We found no effect on perforation rates, hospital LOS, or OR time when symptomatology duration was compared independently with timing of surgery. Pediatric patients with appendicitis presenting with greater than 48 hours of symptomatology had 4.9 times increased odds of perforation and 56% greater hospital LOS than those presenting within 0 to 23 hours. We were unable to demonstrate a difference in perforation rates based on emergency department LOS before surgery.

Meta-analysis of Air Versus Liquid Enema for Intussusception Reduction in Children.

The purpose of this study was to assess the effectiveness and safety of air versus liquid enema reduction in the treatment of intussusception in children. Literature searches of the PubMed, Embase, and Cochrane Library databases were conducted from January 1, 1966, through May 31, 2013. Articles on the use of air or liquid enema in children with a confirmed diagnosis of intussusception and reporting either a success rate for enema reduction of intussusception or a perforation rate were selected. Enema reduction success rate, perforation rate, and recurrence rate were the main outcomes and were calculated by random effects modeling. One hundred two articles (101 reporting success rate, 71 reporting perforation rate) were included that presented results for 32,451 children (age range, 1 day-22 years; boys, 66%; girls, 34%). In 44 studies (16,187 children), the combined estimate for success rate of air enema was 82.7% (95% CI, 79.9-85.6%; inconsistency index [I(2)] = 97%), and in 52 studies (13,081 children) of liquid enema, it was 69.6% (95% CI, 65.0-74.1%; I(2) = 98%). In 38 studies (15,752 children), the combined estimate of perforation rate for air enema was 0.39% (95% CI, 0.23- 0.55%; I(2) = 40%), and in 30 studies (9429 children) of liquid enema, it was 0.43% (95% CI, 0.24- 0.62%; I(2) = 9%). Among 10,494 children (26 studies) undergoing air enema reduction, the rate of first intussusception recurrence was 6% (95% CI, 4.5-7.5%; I(2) = 89%), similar to the 7.3% (95% CI, 5.8-8.8%; I(2) = 71%) found for 4004 children (24 studies) undergoing liquid enema reduction. Air enema was superior to liquid enema for intussusception reduction. The success rate was higher without a difference in perforation rate. Limitations included heterogeneity and publication bias.

Risk of uterine perforation with levonorgestrel-releasing and copper intrauterine devices in the European Active Surveillance Study on Intrauterine Devices

ObjectivesThe objectives were to identify and compare the incidence of uterine perforation and other medically adverse events associated with levonorgestrel-releasing intrauterine systems (LNG-IUSs, releasing 20 mcg LNG daily) and copper intrauterine devices (IUDs) under routine conditions of use in a study population representative of typical users. Methods and materialsThis is a multinational, prospective, non-interventional cohort study with new users of LNG-IUSs and copper IUDs. In addition to a baseline questionnaire, women and their treating health care professional completed a single follow-up questionnaire after 12months. All patient-reported outcomes were validated by the treating physicians. ResultsA total of 61,448 women in six European countries were followed between 2006 and 2013 for more than 68,000 women-years of observation (70% LNG, 30% copper devices). Overall, 81 uterine perforations were reported: 61 for LNG-IUSs [1.4 per 1000 insertions (95% confidence interval {CI}: 1.1–1.8)] and 20 for copper IUDs [1.1 per 1000 insertions (95% CI: 0.7–1.7)], for an adjusted risk ratio (RRadj) of 1.6 (95% CI: 1.0–2.7) when adjusted for age, body mass index, breastfeeding at time of insertion and parity. Breastfeeding at time of insertion was associated with a sixfold increase (RR 6.1, 95% CI: 3.9–9.6), with no differences between LNG and copper IUD users. Sixty-three of the total 81 perforations were associated with previously suspected risk factors (e.g., breastfeeding, time since last delivery ≤36weeks). No perforations led to serious illness or to injury of intra-abdominal or pelvic structures. ConclusionsUterine perforation incidence in this study was low, with a benign clinical course thereafter. The LNG-IUSs and copper IUDs did not have clinically important differences in perforation rates. ImplicationsThe European Active Surveillance Study on Intrauterine Devices is the first large-scale, prospective, noninterventional study to compare the perforation risk in LNG-IUS and copper IUD users. It is the first to examine the independent roles that breastfeeding status and postpartum status have on perforation risk. Conducted during routine clinical practice, the findings are generalizable to broader populations.

A Comparative Study of the Incidence of Schneiderian Membrane Perforations during Maxillary Sinus Augmentation with a Sonic Oscillating Handpiece versus a Conventional Turbine Handpiece

Sonic instruments may reduce perforation rates of the schneiderian membrane during lateral window sinus augmentation procedures. This study compares the incidence of membrane perforations using a sonic handpiece with an oscillating diamond insert versus a turbine handpiece with a conventional rotary diamond stone during lateral window sinus augmentation procedures. A retrospective chart analysis identified all lateral window sinus augmentation procedures done during a defined period. Among these procedures, those performed with a sonic handpiece and an oscillating diamond insert (experimental) and those performed with a conventional turbine and rotary diamond stone (conventional) were selected for this study. Reported occurrences of sinus membrane perforations during preparation of the osteotomy and elevation of the sinus membrane, as well as postoperative complications, were recorded and compared between treatment groups. Ninety-three consecutive patients were identified for a total of 130 sinus augmentation procedures (51 conventional, 79 experimental). Schneiderian membrane perforations were noted during preparation of the lateral window osteotomy in 27.5% of the sinuses in the conventional group and 12.7% of sinuses in the experimental group. During membrane elevation, perforations were noted in 43.1% of the sinuses in the conventional group and 25.3% of sinuses in the experimental group. Both differences in perforation rates were statistically significant (p < .05). There was no statistically significant difference in postoperative complications. In this study, the use of a sonic instrument to prepare the lateral window osteotomy during sinus elevation procedures resulted in a reduced perforation rate of the Schneiderian membrane compared with the conventional turbine instrument.