Incidence Of Perforation Research Articles

Su1158 Through-the-Scope Hydrostatic Balloon Dilation of Strictures and Rings is Associated With Low Incidence of Perforation in Adults With Eosinophilic Esophagitis and Dysphagia: the Four-Year Experience of a Single Tertiary-Care Medical Center

Su1158 Through-the-Scope Hydrostatic Balloon Dilation of Strictures and Rings is Associated With Low Incidence of Perforation in Adults With Eosinophilic Esophagitis and Dysphagia: the Four-Year Experience of a Single Tertiary-Care Medical Center

Factors predicting perforation during endoscopic submucosal dissection for gastric cancer

Perforation is a common complication of endoscopic submucosal dissection (ESD), but little is known about the relevant risk factors. To investigate the risk factors for perforation. Retrospective study. A cancer referral center. A total of 1795 early gastric tumors in 1500 patients treated by ESD from July 2002 to December 2010 were included in the analysis. The associations between the incidence of perforation and patient and lesion characteristics were investigated. Perforation during ESD occurred in 50 lesions (2.8%). Univariate analysis identified tumor location (upper, middle, or lower stomach), tumor diameter (≤ 20 or >20 mm), and treatment period (lesions treated in the first or second period) as predictors of perforation. Multivariate analysis identified tumor location (upper stomach), tumor diameter (>20 mm), and treatment period (first half) as independent risk factors for perforation. The odds ratios were 2.4 (95% CI, 1.3-4.7; P = .006) for lesions in the upper stomach and 1.9 (95% CI, 1.0-3.5; P = .04) for lesions larger than 20 mm. Perforation risks were 5.4% for lesions in the upper stomach and 4.4% for lesions larger than 20 mm. Three patients required emergency surgery, but the rest of the patients were successfully treated with endoscopic clipping. There was no perforation-related mortality. Single-center, retrospective study design. Lesions in the upper stomach and lesions larger than 20 mm were independent risk factors for perforation during ESD. Patients should be made aware of the estimated high risks of these lesions before undergoing ESD.

Mo1255 Management of Duodenal Perforations After Upper Endoscopic Procedures: Is a Non-Surgical Approach Tenable?

Management of Duodenal Perforations After Upper Endoscopic Procedures: Is a Non-Surgical Approach Tenable? Alejandro L. Suarez*, Dennis Collins, Anand Gupte, Shailendra S. Chauhan, Peter V. Draganov, Christopher E. Forsmark, Mihir S. Wagh Division of Gastroenterology, University of Florida, Gainesville, FL Background: Duodenal perforation is a rare but serious endoscopic complication. Management of duodenal perforations is not standardized and surgical intervention has been the traditional approach. Aim: To review the incidence, management and outcomes of duodenal perforations after upper endoscopic procedures. Methods: A retrospective review of our electronic endoscopic complications database and medical records was performed to identify patients with duodenal perforations after upper endoscopic procedures (EGD/ enteroscopy, EUS, ERCP) from 1/2000 8/2011. The study was approved by the IRB at the University of Florida. Medical records were reviewed to collect data on incidence, management and outcomes after duodenal perforation. Data collected included procedure indication, type of endoscopic procedure, time of diagnosis, radiologic test results, management via surgery or conservative measures, length of hospital stay and mortality. Results: 43,572 upper endoscopic procedures were performed during this period [30,038 EGDs (69%), 7,761 ERCPs (18%), 5,773 EUS (13%) ] leading to 18 duodenal perforations (0.04%). 6/18 (33%) perforations resulted from diagnostic procedures while 12/18 (67%) were from therapeutic endoscopies including duodenal EMR/polypectomy, dilation, EUS-FNA, sphincterotomy and stent placement. 8/18 (44%) were identified during endoscopy, 5/18 (28%) within 24 hours and 5/18 (28%) after 24 hours after endoscopy. 16/18 (88%) had radiographic imaging (15 CT scans and 1 abdominal X-ray) while 2 went straight to surgery. Overall, 12/18 (67%) underwent surgery with a mean length of stay of 28 days while 6/18 (33%) were treated conservatively with a mean length of stay of 10 days. Intraperitoneal free air was seen in 73% and retroperitoneal air was seen in 27%. Abdominal CT scan with oral contrast was used to detect duodenal extravasation and leak. Contrast extravasation was seen in 4/15 (27%) with all 4 patients (100%) undergoing surgery (2/4, 50% survived with a mean length of stay 13.5 days). Extravasation of contrast was not seen on CT in 11/15 (73%). Only 5/11 (45%) had surgery (all 5 survived with a mean length of stay 14 days) while 6/11 (55%) were treated conservatively (NPO, NG tube, IV fluids, antibiotics, percutaneous drain if needed), of which all 6 (100%) survived with a mean length of stay 10.3 days. Complications were seen in 4/18 (22%) patients (1 with fever that resolved with antibiotics, 1 sepsis, 1 post-ERCP pancreatitis and 1 abdominal abscess drained percutaneously). Overall, 2/18 (11%) patients died after duodenal perforation (both patients had contrast extravasation requiring surgery). Conclusion: Though limited by small numbers, our data suggests that patients with duodenal perforation without duodenal contrast extravasation on CT scan may be effectively managed conservatively without surgery.

CT features of peripheral T‐cell lymphoma in the gastrointestinal tract in Chinese population and literature review

The aim of the study was to retrospectively investigate the CT features in peripheral T-cell lymphoma (PTCL) of the gastrointestinal tract in the Chinese population. Computed tomography scans of 15 histopathologically proven cases of PTCL involving the gastrointestinal tract were retrospectively reviewed for characteristics such as sites, multiplicity, morphological features, the pattern and degree of contrast enhancement, lymphadenopathy, involvement of other organs and complications such as perforation, intussusceptions, ascites and so on. By reviewing the literature, CT findings of PTCL involving the gastrointestinal tract were compared with that involved by B-cell lymphoma. PTCLs involved the stomach and intestine in six and nine patients, respectively. Multiplicity was seen in seven patients, and solitary involvement was seen in eight. At CT, wall thickening was the predominant finding in all cases with an exception of one intestinal PTCL case presented as polypoid mass. Among the 14 patients, the gastric or bowel wall thickening was mild (<10 mm) in three, moderate (10-20 mm) in 10 and severe (>20 mm) in one. Nine cases demonstrated mild homogeneous enhancement, whereas six showed mild heterogeneous enhancement. Lymphadenopathy was present in eight patients, five of which were non-bulky (diameter <5 cm) and diffuse type and the rest (three) were non-bulky and localised type. Other organs were involved in four patients. Perforation as complication was evident in one gastric and five intestinal lymphomas (55.6%). Among the nine intestinal PTCLs, seven of the patients were male (77.9%) and the rest (two) were female with a median age of 37.1 years old. Intestinal PTCLs predominantly involved colon (n = 5). Other sites of involvement were ileum (n = 1), ileocaecum (n = 1), ileum and ileocaecum (n = 1) and entire bowel segment from distal ileum to transverse colon (n = 1). PTCLs have some distinguishing radiological features from B-cell type gastrointestinal lymphomas as mild or moderate gastric or bowel wall thickening and higher incidence of perforation with multiplicity. In China, intestinal PTCLs are not usually associated with coeliac disease and commonly present in a young male population with colon being the most frequent site of involvement.

A Prospective Analysis of Glove Perforation in Primary and Revision Total Hip and Total Knee Arthroplasty

Literature in regard to glove perforation rates in revision total joint arthroplasty (TJA) is scarce. Our purpose was to determine the incidence of perforation in revision TJA. Gloves from all scrubbed personnel were tested based on the American Society for Testing and Materials. A total of 3863 gloves were collected from 58 primary and 36 revision arthroplasty cases. Surgeons had a 3.7% outer-glove perforation rate in primary TJA compared with 8.9% in revision TJA. When both gloves were perforated, the outer-glove perforation was recognized intraoperatively 100% of the time, and the inner-glove perforation was noted only 19% of the time. The surgeon has the highest rate of glove perforation. Outer-glove perforations should prompt careful inspection of the inner glove.

Trends in the incidence of intestinal perforation in US dialysis patients (1992-2005)

Little is known about the incidence of intestinal perforation in patients undergoing dialysis. Concerns exist that sevelamer hydrochloride may increase the risk of intestinal perforation. We examined long-term trends for the incidence of intestinal perforation among US dialysis patients. We studied all dialysis patients (1992-2005) who had Medicare as primary payer. We used ICD-9 diagnosis code 569.83 to ascertain events of intestinal perforation. We studied (a) all perforations and (b) perforations that did not appear to be associated with specific causative conditions (specific diseases or iatrogenic procedures within 7 days of perforation). We used Poisson regression to model the annual number of intestinal perforations and tested for any changes in levels and temporal trends of incidence rates before versus after January 1, 1999. Overall, 1,060,132 patients contributed 2.7 million patient-years. We observed 12,355 events of intestinal perforation and 7,814 spontaneous perforations. The corresponding incidence rates were 4.6 (total) and 2.9 (spontaneous perforation) episodes per 1,000 person-years, respectively. For both outcome definitions, 30-day mortality was 42%. Unadjusted and adjusted incidence rates were not materially different over time. Formal tests for any changes in the level or slope of incidence comparing time periods before and after January 1, 1999, indicated no evidence for any changes in the incidence of intestinal perforation over time. In US dialysis patients, incidence of intestinal perforation was low, but associated with high short-term mortality. We did not detect any significant changes in the incidence of intestinal perforation before versus after approval of sevelamer hydrochloride in late 1998.

Risk factors for perforations associated with endoscopic submucosal dissection in gastric lesions: emphasis on perforation type

Endoscopic submucosal dissection (ESD) enables en bloc resection of larger gastric neoplasms. However, the procedure is associated with a high incidence of perforation. Perforations during ESD are divided into macro- and microperforations. Although both types of perforations could cause widespread tissue injury and secondary sepsis, very little is known concerning the risk factors for perforations according to the type of perforation. Thus, this study was performed to evaluate the risk factors for macro-, micro-, and all perforations (both) during ESD. 823 gastric lesions (gastric adenoma or early gastric cancer) in 729 patients treated by ESD were enrolled, and their records were reviewed retrospectively. Risk factors were evaluated, focusing on age, sex, gastric neoplasm-related factors (12 locations, resected size, gross type of lesions, presence of ulceration, presence of fibrosis, pathologic diagnosis, and depth of invasion), and ESD procedure-related factors (type of knife, immediate bleeding during ESD, en bloc resection, procedure time, and the number of ESD cases experienced by the endoscopist). Of the 823 gastric lesions, the rates of all perforation, macroperforation, and microperforation were 9.6%, 7.5%, and 2.1%, respectively. Risk factors for all perforations on multivariate analysis were location of tumor in upper portion, presence of fibrosis, and long procedure time (>2 h). Risk factors for macroperforations were the same as all perforations. Risk factors for microperforations on multivariate analysis were old age (≥81 years), depth of invasion (muscularis mucosa), and long procedure time (>2 h). The risk factors for perforations during ESD could differ according to the type of perforation. Therefore, although macroperforation did not develop during ESD, it would be necessary to consider the possibility of microperforation in case of old age, long procedure time, and (deep) depth of invasion.

Is an intra-oesophageal bougie of use during Nissen fundoplication?

A best-evidence topic was written according to a structured protocol. The question addressed was whether the use of an intra-oesophageal bougie during Nissen fundoplication reduces post-operative dysphagia. A total of 34 papers were found using the reported searches of which eight represented the best evidence to answer the clinical question. The authors, date, journal, study type, population, main outcome measures and results are tabulated. The popularity of bougie placement is likely to have been encouraged by an early study reported in this article in 1986 associating the use of a larger bougie with reduction of postoperative dysphagia. A more recent randomized study in 2000 also associated the use of bougie with significantly less long-term and severe dysphagia. Four retrospective studies showed no advantage from the use of a bougie, and the potential benefit are countered by the largest published series in the literature reporting the incidence of oesophageal perforation owing to bougie placement at 0.8%. Despite this risk, a survey of 393 German surgeons in 2005 revealed that 46% use a bougie. In summary, we conclude that there is some evidence to suggest that both the presence and size of bougie may have an impact on dysphagia. The evidence is not substantial enough to recommend change in clinical practice and its use must be weighed against the risk of oesophageal injury which patients should be consented for. These conclusions are in accordance with the 2010 Guidelines for Surgical Treatment of Gastroesophageal Reflux disease by the Society of American Gastrointestinal and Endoscopic Surgeons who give a Grade B recommendation for the placement of an oesophageal dilator. It is important that future studies are adequately powered and designed to measure longitudinal outcomes such as dysphagia severity with validated assessment tools at appropriate follow-up points. The measurement and usefulness of health-related quality of life needs to be investigated further in this patient population.

Iatrogenic colonoscopic perforations: a review of 8 158 patients

Purpose. The aim of the study is to determine the incidence of perforation after colonoscopy (CP) in our institution, and to evaluate the endoscopic information, clinical presentation, diagnosis workup, intra-operative findings, management and outcomes of patients with CP. Methods. All colonoscopies performed between January 2005 and December 2011 at the Oncology Institute of Vilnius University, Lithuania, searched for colonoscopic perforations. Medical records of all CP patients were reviewed. Incidence of CP, patients’ characteristics, endoscopic information, intra-operative findings, management and outcomes were analyzed. Results. A total of 8,158 colonoscopies (7,467 diagnostic and 691 therapeutic) were performed in our hospital over a 7-year period. Five patients (0.061%) had CP: 2 from diagnostic colonoscopy (incidence 0.027%) and 3 from therapeutic one (0.43%). In two cases, perforation was noticed by the endoscopist through visualization of extra-intestinal tissue during the procedure. Other perforations (n = 3, 60%) were diagnosed after the procedure. The most consistent symptom was abdominal pain followed by tenderness, abdominal distension, leukocytosis. The most common site of perforation was in the sigmoid colon (n = 3, 60%). Perforations were caused by direct trauma from the endoscope (n = 2, 40%) and endoscopic polypectomy (n = 3, 60%). All patients with CP underwent surgical management: primary repair. The mortality rate was 0% and the postoperative complication rate was 40%. Conclusions. CP is a serious but rare complication of colonoscopy. Incidence of CP was 0.061%. Therapeutic procedures have a higher perforation risk than diagnostic procedures. The sigmoid colon is the area at the greatest risk of perforation. Surgery is still the mainstay of CP management.

Endoscopic papillary balloon dilatation versus endoscopic sphincterotomy in the treatment for choledocholithiasis: A meta‐analysis

Endoscopic papillary balloon dilatation (EPBD) and endoscopic sphincterotomy (EST) are two common nonsurgical treatments endoscopic retrograde cholangiopancreatography (ERCP) for choledocholithiasis. The aim of this study was to compare the efficacy and safety of EPBD and EST in the treatment for choledocholithiasis, confining the analysis to work reported in the last decade. The rate of overall postoperative complications was chosen as the primary outcome, and 10 other outcomes were secondary outcomes. Relative risk (RR) or Peto odds ratio (OR) were computed as the measures of pooled effects. We planned sensitivity analyses a priori for examining the change in robustness of the sensitivity to excluding studies with some inappropriate objects, technique defects or without full-text acquisition. For complete stone removal, EPBD was similar to EST (95% vs. 96%, P = 0.36) and overall postoperative complications (14.0% vs. 11.7%, P = 0.53). The incidence of post-ERCP cholangitis (2.5% vs. 1.8%, P = 0.40), basket impaction (0.9% vs. 0%, P = 0.16) and perforation (0.0% vs. 0.4%, P = 0.17) were equivalent between EPBD and EST. On the other hand, EPBD caused more post-ERCP pancreatitis (PEP) (9.4% vs. 3.3%, P < 0.00001), but less hemorrhage (0.1% vs. 4.2%, P < 0.00001). People undergoing EPBD required more use of endoscopic mechanical lithotripsy (35.0% vs. 26.2%, P = 0.0004). The results of sensitivity analyses showed no substantial change. EPBD is comparable to EST for stone extraction, though it requires more endoscopic mechanical lithotripsy (EML). EPBD may outweigh EST for patients with coagulopathy; however, it may cause more PEP.

Systematic review and meta-analysis of randomized clinical trials of self-expanding metallic stents as a bridge to surgery versus emergency surgery for malignant left-sided large bowel obstruction

Use of self-expanding metallic stents (SEMS) as a bridge to surgery has been suggested as an alternative management for acute malignant left-sided colonic obstruction, as emergency surgery has a high risk of morbidity and mortality. This meta-analysis evaluated high-quality evidence comparing preoperative SEMS with emergency surgery. Relevant randomized clinical trials (RCTs) were identified from the Cochrane Central Register of Controlled Trials, MEDLINE, Embase and PubMed (1990-2011). Primary outcomes were primary anastomosis, stoma and in-hospital mortality rates. Secondary outcomes included anastomotic leak, 30-day reoperation and surgical-site infection rates. Four RCTs with 234 patients were included. Technical and clinical success rates for stenting were 70·7 per cent (82 of 116) and 69·0 per cent (80 of 116) respectively. The clinical perforation rate was 6·9 per cent (8 of 116) and the silent perforation rate 14 per cent (11 of 77). SEMS intervention resulted in significantly higher successful primary anastomosis (risk ratio (RR) 1·58, 95 per cent confidence interval 1·22 to 2·04; P < 0·001) and lower overall stoma (RR 0·71, 0·56 to 0·89; P = 0·004) rates. There was no difference in primary anastomosis, permanent stoma, in-hospital mortality, anastomotic leak, 30-day reoperation and surgical-site infection rates. Three trials were stopped prematurely, one because the emergency surgery group had a significantly increased anastomotic leak rate, and two others because of stent-related complications and increased 30-day morbidity following SEMS management. Technical and clinical success rates for stenting were lower than expected. SEMS is associated with a high incidence of clinical and silent perforation. However, as a bridge to surgery, SEMS has higher successful primary anastomosis and lower overall stoma rates, with no significant difference in complications or mortality.

Effectiveness of Bevacizumab With First-Line Combination Chemotherapy for Medicare Patients With Stage IV Colorectal Cancer

Clinical trials have shown that adding bevacizumab to cytotoxic chemotherapy improves survival for patients with colorectal cancer, although its effectiveness in the Medicare population is uncertain. Using the Surveillance, Epidemiology, and End Results (SEER) -Medicare linked database, we identified 2,526 patients with stage IV colorectal cancer diagnosed between 2002 and 2007 who received first-line combination chemotherapy with a fluoropyrimidine and either irinotecan (33%) or oxaliplatin (67%). Thirty-six percent of patients received bevacizumab with first-line therapy. The primary outcome was overall survival. Secondary outcomes were bevacizumab-associated toxicities, including the incidence of stroke, myocardial infarction, and GI perforation. In the primary cohort inclusive of patients diagnosed between 2002 and 2007, bevacizumab with combination chemotherapy was associated with improved overall survival (adjusted hazard ratio [HR], 0.85; 95% CI, 0.78 to 0.93), although the effect was more modest when restricted to years 2004 to 2007 (HR, 0.93; 95% CI, 0.84 to 1.02). The observed survival advantage of bevacizumab was more apparent with irinotecan-based chemotherapy (HR, 0.80; 95% CI, 0.66 to 0.97) than with oxaliplatin-based chemotherapy (HR, 0.96; 95% CI, 0.86 to 1.07). Combination chemotherapy with bevacizumab, versus combination chemotherapy without bevacizumab, was associated with increased risk of stroke (4.9% v 2.5%, respectively; P < .01) and GI perforation (2.3% v 1.0%, respectively; P < .01). Cardiac events and venous thrombosis were not increased with bevacizumab. The addition of bevacizumab to cytotoxic combination chemotherapy was associated with small improvement in overall survival as well as increased risk of stroke and perforation, but not cardiac events, among Medicare beneficiaries with stage IV colorectal cancer.

Incidence, Management and Prognosis of Coronary Perforations

ABSTRACT Background Coronary perforation is currently a rare, but potentially catastrophic complication. The aim of the study was to evaluate the incidence, predictors, management and prognosis of coronary perforations at a hospital with a large number of percutaneous coronary interventions (PCIs). Methods Clinical, angiographic, procedural and in-hospital outcomes of patients with or without coronary perforations were compared. Univariate analysis was performed to determine the predictors of this complication. Results From December 2007 to January 2012, 5,585 consecutive patients were submitted to PCI and 18 had coronary perforation (0.32%), of whom 55.5% were female and 38.9% were diabetic. In this group, the left anterior descending artery was the most frequently treated vessel (61.1%) as well as type C lesion (61.1%) and chronic occlusions were approached in 27.8% of these cases. Most of the coronary perforations (11/18) had a lower complexity according to the modified Ellis classification, whereas the remaining perforations were classified as grades III (6/18) or IV (1/18). The balloon-catheter device was responsible for perforation in 61.1% of the cases. Prolonged inflation with a balloon-catheter and heparin reversal with protamine was performed in 72.2% and 88.9% of the cases, respectively. Only 1 patient (5.6%) required an emergency surgery due to cardiac tamponade. There were no deaths associated with coronary perforation. According to the univariate analysis, coronary perforation predictors were: female gender (P = 0.03), chronic obstructive pulmonary disease (P = 0.006) and chronic occlusion (P Conclusions In our experience, coronary perforation was a rare event, which was managed conservatively in most of the cases and was associated with a good in-hospital outcome.

Incidência, manejo e prognóstico de perfurações coronárias

INTRODUÇÃO: A perfuração coronária na atualidade é complicação rara, mas potencialmente catastrófica. Nosso objetivo foi avaliar a incidência, os preditores, o manejo e o prognóstico das perfurações coronárias na experiência de um serviço de cardiologia intervencionista com grande volume de intervenções coronárias percutâneas (ICPs). MÉTODOS: Comparamos as características clínicas, angiográficas e do procedimento e a evolução intra-hospitalar de pacientes que apresentaram ou não perfuração coronária. Análise univariada foi realizada para determinar os preditores dessa complicação. RESULTADOS: No período de dezembro de 2007 a janeiro de 2012, 5.585 pacientes consecutivos foram submetidos a ICP e 18 apresentaram perfuração coronária (0,32%), dos quais 55,5% eram do sexo feminino e 38,9% eram diabéticos. Nesse grupo, a artéria descendente anterior foi o vaso mais frequentemente tratado (61,1%), assim como a lesão do tipo C (61,1%), e as oclusões crônicas foram abordadas em 27,8% desses casos. A maioria das perfurações coronárias (11/18) apresentou menor complexidade de acordo com a classificação de Ellis modificada, enquanto as demais foram qualificadas como graus III (6/18) ou IV (1/18). O cateter-balão foi o dispositivo responsável pela perfuração em 61,1% dos casos. Realizou-se insuflação prolongada com cateter-balão e inativação da heparina com protamina em 72,2% e 88,9% dos casos, respectivamente. Apenas 1 paciente (5,6%) necessitou de abordagem cirúrgica de emergência em decorrência de tamponamento cardíaco. Não houve óbito associado à perfuração coronária. Na análise univariada, os preditores de perfuração coronária foram: sexo feminino (P = 0,03), doença pulmonar obstrutiva crônica (P = 0,006) e oclusão crônica (P < 0,01). CONCLUSÕES: Em nossa experiência, a perfuração coronária foi evento raro, controlada conservadoramente na maioria dos casos e com evolução hospitalar satisfatória.

Analysis of colonoscopic perforations at a local clinic and a tertiary hospital

To define the clinical characteristics, and to assess the management of colonoscopic complications at a local clinic. A retrospective review of the medical records was performed for the patients with iatrogenic colon perforations after endoscopy at a local clinic between April 2006 and December 2010. Data obtained from a tertiary hospital in the same region were also analyzed. The underlying conditions, clinical presentations, perforation locations, treatment types (operative or conservative) and outcome data for patients at the local clinic and the tertiary hospital were compared. A total of 10 826 colonoscopies, and 2625 therapeutic procedures were performed at a local clinic and 32 148 colonoscopies, and 7787 therapeutic procedures were performed at the tertiary hospital. The clinic had no perforations during diagnostic colonoscopy and 8 (0.3%) perforations were determined to be related to therapeutic procedures. The perforation rates in each therapeutic procedure were 0.06% (1/1609) in polypectomy, 0.2% (2/885) in endoscopic mucosal resection (EMR), and 3.8% (5/131) in endoscopic submucosal dissection (ESD). Perforation rates for ESD were significantly higher than those for polypectomy or EMR (P < 0.01). All of these patients were treated conservatively. On the other hand, three (0.01%) perforation cases were observed among the 24 361 diagnostic procedures performed, and these cases were treated with surgery in a tertiary hospital. Six perforations occurred with therapeutic endoscopy (perforation rate, 0.08%; 1 per 1298 procedures). Perforation rates for specific procedure types were 0.02% (1 per 5500) for polypectomy, 0.17% (1 per 561) for EMR, 2.3% (1 per 43) for ESD in the tertiary hospital. There were no differences in the perforation rates for each therapeutic procedure between the clinic and the tertiary hospital. The incidence of iatrogenic perforation requiring surgical treatment was quite low in both the clinic and the tertiary hospital. No procedure-related mortalities occurred. Performing closure with endoscopic clipping reduced the C-reactive protein (CRP) titers. The mean maximum CRP titer was 2.9 ± 1.6 mg/dL with clipping and 9.7 ± 6.2 mg/dL without clipping, respectively (P < 0.05). An operation is indicated in the presence of a large perforation, and in the setting of generalized peritonitis or ongoing sepsis. Although we did not experience such case in the clinic, patients with large perforations should be immediately transferred to a tertiary hospital. Good relationships between local clinics and nearby tertiary hospitals should therefore be maintained. It was therefore found to be possible to perform endoscopic treatment at a local clinic when sufficient back up was available at a nearby tertiary hospital.

Incidence, Management and Prognosis of Coronary Perforations

Incidence, Management and Prognosis of Coronary Perforations

Heart perforation in patients with permanent cardiac pacing – pilot personal observations

IntroductionHeart perforation is a rare complication of pacemaker (PM)/implantable cardioverter-defibrillator (ICD) implantation.Material and methodsIn our clinic in 2005–2010, 6 patients with heart perforation were hospitalized (3 women, 3 men), mean age 58.6 ±20.8 years (17 to 73 years). The indication to PM/ICD implantation was tachy-brady syndrome in 3 cases, second-degree atrioventricular block, advanced with losses of consciousness, vaso-vagal syndrome type II B with asystole lasting 12 s and recurrent non-sustained ventricular tachycardia in 1 patient. We analyzed patient's medical records, X-rays, echocardiography, computed tomography (CT) and procedure protocols.ResultsThe incidence of heart perforation was 0.09%. Symptoms developed 4 to 990 days (mean 186.3 ±394.3) after PM/ICD implantation. The perforation site was found in the right atrial wall in 1 cases and the right ventricular wall in 6 cases. The TTE revealed an accumulation of fluid in the pericardium over 10 mm behind the posterior wall of the left ventricle in all patients. The CT scan confirmed perforation of the heart chambers (atrium and in 6 cases ventricle). In 5 cases the whole device was removed by direct traction or percutaneous lead extraction with pericardiocentesis when necessary (pericardium drainage in 3 cases) while in 1 case cardiac surgery was needed.ConclusionsThe perforating lead may be removed by direct traction in the operating room with cardiosurgical, anesthesiological and echocardiographical backup. In case of the lead perforation outside the pericardial sac or its atypical location, cardiac surgery is a safer method. The most important diagnostic method remains computed tomography.

Is harmonic scalpel during laparoscopic cholecystectomy superior than clips and cautery technique?

The standard laparoscopic cholecystectomy is usually performed using a monopolar electrocautery for dissection and clips for occlusion of the cystic duct and cystic artery. Some pitfalls are associated with the use of the monopolar cautery and clips, therefore other alternative techniques have been described. Ultrasonically activated devices have been used for dissection and cystic duct ligation during laparoscopic cholecystectomy (LC) with encouraging results, however it does not gain widespread acceptance among surgeons. The aim of the present study was to compare the surgical outcome of LC performed by the harmonic scalpel to that peiformed by the conventional diathermy and clips. Material and methods: This prospective randomized comparative study included 30 patients (group A) in whom LC was conducted using the conventional method by clipping both the cystic duct and artery with dissection of gallbladder from liver bed by monopolar electrocautery (clips and cautery method = CCM), and 30 patients (group B) who were operated on using laparoscopic harmonic scalpel (LHS) for closure and division of cystic duct and artery and for dissection of gallbladder from liver bed. Our primary end point was the biliary complications; however other intraoperative and postoperative parameters were included: bleeding, duration of operation, postoperative pain, and other complications. Results: Demographic data was similar in both groups. The operative duration was shorter in LHS than CCM (56.3 min vs. 63.3 respectively, p < 0.01), with a significant less incidence of gallbladder peiforation (6.66% vs. 20%, p < 0.001).No postoperative bile leak was encountered in LHS, but it occurred in 3% of patients in CCM No patient developed post operative bleeding in both groups however the amount of postoperative drainage was significantly less in LHS (29 vs. 47.7, p = 0.001). Most of patients were discharged from hospital on 2nd postoperative day; however the delayed discharge was statistically higher in CCM (16.6% vs. 6.66%, p < 0.01). Conclusion: LHS is a reliable, effective and safe tool in LC. It is a good alternative to standard monopolar electrocautery dissection with clipping of cystic duct and artery. It provides a shorter operative duration, less incidence of gallbladder perforation, and less hospital stay. Abbreviations: CCM= Clip and cautery method, LC= Laparoscopic cholecystectomy, LHS= laparoscopic harmonic scalpel, HFMC= high frequency monopolar cautery, BDI= bile duct injury, CBC= complete blood picture, INR= international normalized ratio, LFT= liver function test, UIS= ultrasonography.

Prevalence and risk factors for colonic perforation during colonoscopy in hospitalized end-stage renal disease patients on hemodialysis

Colonic perforation is a rare complication during colonoscopy. A recent single center study reported a high incidence of colonic perforation in end-stage renal disease (ESRD) patients on hemodialysis (HD) who underwent colonoscopy. We sought to determine nationwide, population-based prevalence in rates of colonic perforation during colonoscopy among ESRD inpatients on HD in the US, and to assess risk factors for colonic perforation in this patient population. We obtained patient data from the Nationwide Inpatient Sample and used the International Classification of Diseases, the 9th revision, clinical modification codes, to identify ESRD patients on HD who had undergone colonoscopy in 2006. The control group consisted of inpatients who had colonoscopy without ESRD. Colonic perforations occurred in 51/17,000 ESRD hospitalizations on HD (0.3%) and 3,951/564,428 controls without ESRD (0.7%). The risk of colonic perforation among the study group was not significantly higher than the control group even after adjusting for patient demographics like age, gender and comorbid conditions (adjusted odds ratio [aOR] -0.55; 95% confidence interval [CI], 0.30-0.97). Older age (OR -1.007; 95% CI, 1.002-1.011) and female gender (OR -1.18; 95% CI, 1.03-1.36) were identified as independent risk factors for the risk of perforation in this population group. There appeared no increased risk of colonic perforation during colonoscopy among inpatients who received HD in our study. Increasing age and female patients appeared to be associated with procedure-related colonic perforation.

Late Migration of Percutaneous Bio-Absorbable Devices-A Word of Caution

Closures of atrial septal defects or a patent foramen ovale (PFO) are increasingly performed percutaneously. The experience of late migration of a new bio-absorbable device is presented here, followed by conceptual discussion. Six months post PFO closure with a BioSTAR® device a patient presented with chest pain. Echocardiography showed a hyperechogenic structure perforating the aortic wall. Surgical exploration showed a perforation of the ascending aorta by one metallic, non absorbable arm. This is the second case of late (>6 months) dislocation of the residual framework of the occluder. The overall incidence of perforation of cardiac structures due to secondary dislocation is low. However this complication exists and should kept in mind in symptomatic patients with new onset of chest pain, after percutaneous procedures. The concept of biodegradation, with residual, non absorbable metal braiding, should be reviewed, analyzing in particular long term results and incidence of secondary dislocation.