Instances Of Perforation Research Articles

Short-term outcome of endoscopic submucosal dissection using a clutch cutter for subepithelial lesions within the esophagogastric submucosa: a Japanese prospective observational study.

The efficacy and safety of endoscopic submucosal dissection using a clutch cutter (ESD-CC) for subepithelial lesions within the esophagogastric submucosa (SELEGSM) has not been investigated. This study aimed to assess the efficacy and safety of ESD-CC for the treatment of SELEGSM. This prospective study included 15 consecutive patients with 18 SELEGSMs diagnosed by endoscopic ultrasonography. The primary outcomes were short-term outcomes including en bloc resection rate, R0 resection rate, procedure time, and complication rate. The secondary outcome was final histological diagnosis. Among the participants, 18 lesions were identified: 12 in the stomach (nine patients) and six in the esophagus (six patients). The en bloc resection rate was 94.4% (17/18). The R0 resection rate was 88.9% (16/18). The median operating time was 39 min, and no instances of perforation or bleeding were observed. The final diagnoses of SELEGSM included six neuroendocrine tumors (33.3%), six granular cell tumors (33.3%), two ectopic pancreases (11.1%), one inflammatory fibroid polyp (5.6%), one leiomyoma (5.6%), one lipoma (5.6%), and one leiomyosarcoma (5.6%). ESD-CC appears to be a technically efficient and safe approach for SELEGSM resection, suggesting its potential as a valuable treatment option.

Power-Controlled, Irrigated Radio-Frequency Ablation of Gastric Tissue: A Biophysical Analysis of Lesion Formation

BackgroundRadio-frequency ablation of gastric tissue is in its infancy compared to its extensive history and use in the cardiac field.AimsWe employed power-controlled, irrigated radio-frequency ablation to create lesions on the serosal surface of the stomach to examine the impact of ablation power, irrigation, temperature, and impedance on lesion formation and tissue damage.MethodsA total of 160 lesions were created in vivo in female weaner pigs (n = 5) using a combination of four power levels (10, 15, 20, 30 W) at two irrigation rates (2, 5 mL min−1) and with one temperature-controlled (65 °C) reference setting previously validated for electrophysiological intervention in the stomach.ResultsPower and irrigation rate combinations above 15 W resulted in lesions with significantly higher surface area and depth than the temperature-controlled setting. Irrigation resulted in significantly lower temperature (p < 0.001) and impedance (p < 0.001) compared to the temperature-controlled setting. No instances of perforation or tissue pop were recorded for any ablation sequence.ConclusionPower-controlled, irrigated radio-frequency ablation of gastric tissue is effective in creating larger and deeper lesions at reduced temperatures than previously investigated temperature-controlled radio-frequency ablation, highlighting a substantial improvement. These data define the biophysical impact of ablation parameters in gastric tissue, and they will guide future translation toward clinical application and in silico gastric ablation modeling.Graphical Combination of ablation settings (10–30 W power, 2–5 mL min-1 irrigation) were used to create serosal spot lesions. Histological analysis of lesions quantified localized tissue damage.

S2327 Single Incision Needle Knife (SINK) Biopsy for Diagnosis of a Large Gastric Subepithelial Lesion After Multiple Failed Fine Needle Aspirations

INTRODUCTION: Subepithelial lesions (SELs) are a group of heterogenous tumors arising from layers below the gastrointestinal (GI) mucosa and are a common incidental finding on upper endoscopy. Although fewer than 15% of SELs are malignant, accurate diagnosis is essential to identify tumors that will need definitive management. Endoscopic ultrasound with fine needle aspiration (EUS-FNA) is an established technique frequently used to sample SELs, but diagnosis can still remain elusive in many instances. We present a case of a large gastric SEL where single incision needle knife (SINK) biopsy successfully produced a histopathologic diagnosis after multiple failed attempts with EUS-FNA. CASE DESCRIPTION/METHODS: A 66-year-old woman with epigastric pain, weight loss and early satiety underwent CT imaging that showed a 4.5 cm exophytic gastric mass. Initial EUS revealed a subepithelial, hypoechoic lesion with smooth borders and intraluminal convexity along the greater curvature of the stomach. It originated from the muscularis propria and measured 27 mm in depth. Two attempts with EUS-FNA at an outside hospital were non-diagnostic. At our center, EUS-FNA involving multiple passes with 22 and 25-gauge needles was also inconclusive. EUS was then repeated using the SINK biopsy technique. After exclusion of overlying vasculature and circumferential epinephrine injection, a 10 × 5 mm (length x depth) needle knife incision was made at the area of highest convexity over the lesion. A biopsy forceps was inserted into the defect for direct tissue sampling. Minor bleeding post-biopsy was treated with additional epinephrine and two hemostatic clips. A histologic diagnosis of GIST was made and the patient was referred for surgical resection as definitive management. DISCUSSION: This case highlights the limitations of EUS-FNA, while also providing further evidence to support SINK biopsy as a safe and effective technique. The reported yield for histologic diagnosis in upper GI SELs using SINK biopsy is between 81% and 92%. In cases with failed conventional biopsy or EUS-FNA, subsequent SINK biopsy has success rates ranging from 75% to 92%. No instances of perforation have been reported with SINK biopsy. As current ASGE guidelines do not endorse a standard biopsy method, the increased diagnostic yield and strong safety profile of SINK biopsy performed by experienced endoscopists suggests it should be the preferred technique over repeated EUS-FNA in cases of SELs with intraluminal convexity and prior non-diagnostic sampling.Figure 1.: Endoscopic Ultrasound (EUS) image of large gastric (greater curvature) subepithelial lesion arising from the muscularis propria with intraluminal convexity.Figure 2.: 10 × 5 mm (length x depth) incision of overlying mucosa using needle knife (Endo Cut).Figure 3.: Histology of sample obtained by SINK biopsy showing (A) proliferative and atypical spindle cells (hematoxylin and eosin, 20x), (B) positive DOG-1 staining (20x) and (C) positive C-KIT staining (20x).

886 Underwater Endoscopic Mucosal Resection May Only Be Superior to Conventional Endoscopic Mucosal Resection for the Treatment of Colorectal Polyps 4 CM or Larger

INTRODUCTION: Underwater endoscopic mucosal resection (UEMR) is an alternative to conventional submucosal-lift EMR (CEMR) for removal of large non-pedunculated colorectal polyps. Retrospective studies have suggested that UEMR may be more effective at reducing lesion recurrence than CEMR, when performed by experts in this technique. The aim of this study was to compare the generalized safety and effectiveness of UEMR to CEMR for removal of large colorectal polyps when performed by expert endoscopists at a tertiary referral center. METHODS: Patients who had UEMR or CEMR performed by one of 7 experienced endoscopists (&gt;50 large polyp resections/year) at a single university-based health system between 3/2015 and 7/2018 were included. Each of the 7 endoscopists regularly performed CEMR but adopted UEMR before or during this study. Patients were identified retrospectively using CPT codes and data was collected from our electronic medical record. RESULTS: 186 patients who underwent 142 UEMR and 98 CEMR procedures were included (Table 1). Mean size of polyps removed was 30.7 mm (range: 15-120 mm) for UEMR and 25.3 mm (range: 15- 50 mm) for CEMR (P = 0.001). There were a significantly greater number of tubulovillous adenomas in the UEMR group (22% vs. 37%, P = 0.02). For polyps ≥4 cm, the residual polyp rate on the first follow-up colonoscopy was 26% for UEMR and 60% for CEMR (OR 4.2, P = 0.05), as confirmed by biopsies. However, there was no statistically significant difference between UEMR vs. CEMR for lesion recurrence for polyps &lt; 4 cm in size. For all polyp sizes, there was no difference in rates of complete macroscopic resection, en bloc resection, number of colonoscopies to reach clearance, and need for adjunctive resection techniques (i.e., argon plasma coagulation, hot biopsy avulsion) between the groups (Table 2). There were no instances of perforation. No significant differences in rates of intra-procedural or delayed procedural bleeding were found between groups (Table 3). CONCLUSION: When generalized across multiple endoscopists at a university-based health system, there was no observed benefit of UEMR compared to CEMR for colorectal polyps under 4 cm in size. However, for lesions 4 cm and greater, UEMR was superior in terms of reduced rates of residual lesion at the first follow-up colonoscopy. Prospective trials are required to further delineate the comparative impact of UEMR vs. CEMR with respect to rates of residual neoplasia.

Long-term outcomes of combined endoscopic resection and chemoradiotherapy for esophageal squamous cell carcinoma with submucosal invasion

BackgroundFor esophageal squamous cell carcinoma (ESCC) with submucosal (SM) invasion, surgery is the standard treatment. Definitive chemoradiotherapy (D-CRT) is a less invasive alternative option, but sometimes results in locoregional failure. AimTo examine whether endoscopic resection for primary lesion removal combined with chemoradiotherapy (ER-CRT) reduces locoregional failure rates in cases of ESCC with SM invasion. MethodsWe retrospectively compared clinical outcomes between ER-CRT and D-CRT in patients diagnosed with ESCC with SM invasion between 2003 and 2014. Twenty-one patients underwent ER-CRT based on a pathological diagnosis, and 43 patients underwent D-CRT based on a clinical diagnosis. ResultsLocoregional failure developed in 26% of patients in the D-CRT group, and in no patients in the ER-CRT group (p < 0.01). Thus, the 5-year relapse-free survival in the ER-CRT group was significantly more favorable than that in the D-CRT group (85.1% vs 59.2%; p < 0.05), although there was no difference in overall survival (85.1% vs 79.1%) nor in cause-specific survival (90.5% vs 87.2%) between the groups. There were no instances of perforation or hemorrhage associated with ER. ConclusionER-CRT is a safe and effective treatment strategy and can be considered as a new minimally invasive treatment option for patients with ESCC with SM invasion.

Cement Removal from the Femur Using the ROBODOC System in Revision Total Hip Arthroplasty

Introduction. The perforation and fracture of the femur during the removal of bone cement in revision total hip arthroplasty (THA) are serious complications. The ROBODOC system has been designed to selectively remove bone cement from the femoral canal, but results have not been reported yet. The purpose of our study was to evaluate the clinical and radiographic results of revision THA using the ROBODOC system for cement removal. Materials and Methods. The subjects comprised 19 patients who underwent revision THA using the ROBODOC system. The minimum duration of follow-up was 76 months (median, 109 months; range, 76–150 months). The extent of remaining bone cement on postoperative radiography, timing of weight bearing, and the complications were evaluated. Results. The mean Merle d'Aubigne and Postel score increased from 10 points preoperatively to 14 points by final follow-up. Bone cement was completely removed in all cases. Full weight bearing was possible within 1 week after surgery in 9 of the 19 cases and within 2 months in all remaining cases. No instances of perforation or fracture of the femur were encountered. Conclusions. Bone cement could be safely removed using the ROBODOC system, and no serious complications occurred. Full weight bearing was achieved early in the postoperative course because of circumferential preservation of the femoral cortex.

Endoscopic ultrasound rendezvous for bile duct access using a transduodenal approach: cumulative experience at a single center. A case series

Endoscopic ultrasound (EUS)-assisted biliary access is utilized when conventional endoscopic retrograde cholangiopancreatography (ERCP) fails. We report a 10-year experience utilizing a transduodenal EUS rendezvous via a transpapillary route without dilation of the transduodenal tract, followed by immediate ERCP access. Patients included all EUS-guided rendezvous procedures for biliary access that were performed following ERCP failure. EUS-assisted bile duct puncture was performed via a transduodenal approach and a guide wire was advanced through the papilla without any dilation or bougienage of the tract; ERCP was performed immediately afterwards. EUS-assisted biliary rendezvous was attempted in 15 patients (mean age 66 +/- 18.2 years; malignant = 10, benign = 5). Mean diameter of measured bile ducts was 14.3 +/- 5.17 mm (range 4-23 mm). The reasons for initial ERCP failure were tumor infiltration or edema (n = 9), intradiverticular papilla (n = 2), pre-existing duodenal stent (n = 1), and anatomic anomalies (n = 3). Successful EUS-guided bile duct puncture and wire passage were achieved in all 15 patients (100 %), with drainage being successful in 12 / 15 (80 %). Failures occurred in three patients due to inability to traverse the biliary stricture (n = 2) or dissection of a choledochocele with the guide wire (n = 1); all were subsequently drained via percutaneous methods. Stents placed were metallic in eight patients and plastic in four. Complications consisted of moderate pancreatitis after a difficult ERCP attempt in one patient, and bacteremia after percutaneous biliary drainage in another. There were no instances of perforation, extraluminal air or fluid collections. EUS-assisted biliary drainage utilizing a transduodenal rendezvous approach demonstated a high success rate without any complications directly attributable to the EUS access. Advantages over percutaneous biliary and other methods of EUS biliary access include performance under the same anesthesia, and a very small-caliber needle puncture similar to EUS/fine-needle aspiration.

Outcomes of acute esophageal food impaction: Success of the push technique

Background: Acute esophageal food impaction (AEFI) is the most common form of esophageal impaction in adults. The current recommendation for management is extraction by using an overtube to protect the airway, which facilitates multiple passages of the endoscope and protects the esophageal mucosa. Typically, AEFI in our patients is treated with the push technique, a method found to be highly successful and without complications. Methods: All patients with a diagnosis of AEFI from 1993 to 1998 were identified by computer search of ICD-9 diagnosis code 935.1 (foreign body of the esophagus). Patients were excluded if they were less than 18 years of age, had an acute esophageal foreign body other than food, or if the medical record was incomplete. Results: The analysis included 189 patients: 114 men and 75 women. Of these, 77 (41%) had a Schatzki's ring, 61 (32%) had an esophageal stricture, and 4 (2%) had esophageal cancer. In 47 patients (25%) no obvious structural cause for AEFI was noted at endoscopy. In addition, 67 patients had breaks in the esophageal mucosa. The push technique resolved the food impaction in 184 of 189 (97%) of the patients. In no subgroup was there an instance of perforation, aspiration, or bleeding. Forty-five patients underwent dilation at the time of food disimpaction without complication. Conclusions: The push technique is both safe and effective in the treatment of AEFI. Dilation at the initial presentation of a patient with AEFI likewise appears to be safe. The push technique is recommended as the initial therapy of choice for AEFI. Dilation at the time of esophageal food disimpaction can be considered if there are no obvious contraindications. (Gastrointest Endosc 2001;53:178-81.)

Laser balloon angioplasty versus balloon angioplasty in normal rabbit iliac arteries

Reduction of vascular recoil is an important goal of laser balloon angioplasty (LBA), wherein Nd:YAG laser radiation is delivered radially during balloon inflation. To define the acute and chronic effects of LBA on the normal arterial lumen in comparison with those of balloon angioplasty (BA), 36 New Zealand White male rabbits (3-4 kg) were subjected to LBA of an external iliac artery and to BA of the contralateral artery with two 1-minute balloon inflations. During LBA, which was performed during the second balloon inflation, either 300 (n = 26) or 176 (n = 10) J were delivered to achieve high and moderate laser doses, respectively, in different LBA groups. Angiography was performed pre- and post-LBA/BA and subsequently at intervals of either 1, 2, 7, 28, 48, or 223 days. Automated analysis of digitized images was used to measure lumen diameter. No instance of perforation or thrombosis occurred. LBA-treated arteries acutely showed an increase in mean diameter over baseline (+ .5 mm, P less than .01) and that of BA-treated arteries (+ .4 mm, P less than .01). While arteries treated with the high laser dose showed a loss of the initial gain in lumen diameter by 1 month, caused by both extravascular fibrosis of the thinwalled (less than 0.1 mm) artery and mild neointimal proliferation which were not reduced by daily administration of aspirin in seven rabbits, arteries treated with the moderate laser dose retained the increment in mean diameter at 1 month over that of BA-treated arteries (+ .5 mm, P less than .05). Thus, unlike BA, LBA increases luminal diameter acutely and, at a moderate laser dose, chronically.

Proctosigmoidoscopy-incidence of polyps in 50,000 examinations.

• Proctosigmoidoscopy was accomplished in 50,000 cases with but a single instance of perforation by observing these precautions: digital examination of the rectum before inserting the instrument, blind insertion of the instrument only as far as the finger has explored, infrequent use of air inflation, special care in passing diseased segments, and care not to push the instrument forcibly against the intestinal wall until the lumen ahead has been identified. All subjects were asymptomatic and between the ages of 20 and 76. Polyps were found in 3,952 cases. Of these, 328 were malignant. In addition, 19 cases of moderately advanced rectal cancer were also found. Digital examination and proctosigmoidoscopy are effective in early detection of cancer. The early removal of rectal polyps will prevent many carcinomas of the colon.

Perforation of a Gastric Ulcer Associated with Intracranial Hemorrhage in a Newborn Infant

That perforated gastric ulcers are of unusual occurrence in infants and children is well established. In a review of 248 cases of ulceration of the stomach in children, Theile (1, 2) found only 5 instances of perforation. Pendergrass and Booth (3) have also stressed the absolute and relative rarity of this complication in childhood as compared to its incidence in later life. The etiology of ulceration in children, with or without subsequent perforation, is obscure. Adler (4) attributed it to autodigestion occurring as a result of small hemorrhages during parturition. Other causative agents which have been suggested are direct trauma, infection, local disturbance of circulation from congestion, embolism, thrombosis, and vascular disease. The brilliant work of Cushing (5), following that of German investigators (7, 8), established a neurogenic origin for many gastric ulcers. Animal experiments and his observation of multiple ulcers of the stomach, frequently with perforation, following brain surgery, more especially operations in the region of the cerebellum, led him to the conclusion that injury or stimulation in this latter region may lead to the development of peptic ulcer. The establishment of the diagnosis of peptic ulcer in an infant is difficult. The only clinical sign is hemorrhage. According to Hurst and Stewart (9), 50 per cent of cases of melena in infancy are due to peptic ulcer. Roentgen examination should therefore be made, and if necessary repeated at frequent intervals, in any infant with bleeding from the gastro-intestinal tract, in order that an early diagnosis may be made. The following case is believed to be of interest because of the rarity of perforation of gastric ulcer in the newborn, for the association of the condition with intracranial injury, and as illustrating the importance of early roentgen diagnosis. Case Report The patient was a full-term male infant weighing 6 lb. 14 oz., the second child of a Puerto Rican mother. The prenatal course had been normal, and the mother's Mazzini test was negative. Labor pains began at noon, Oct. 9, 1948; the membranes ruptured at 2:30 p.m., and spontaneous delivery occurred at 10:20 p.m. of the same day. The infant was in a vertex presentation, left occiput anterior position. At no time were forceps used, nor was there any undue trauma associated with the birth. The child appeared well until the second day, when he passed two dark red stools and vomited dark brown fluid once. On physical examination he was described as a well nourished, normally developed baby. The skin was pale and free from petechiae. Examination of the head was negative. The chest was clear and the abdomen was soft. Bleeding and clotting times were within normal limits. The white cell count was 5,600, with 86 per cent polymorphonuclears, 10 per cent lymphocytes, and 4 per cent myelocytes; red cell count, 3,320,000; hemoglobin, 11.5 gm.; hematocrit reading, 40. There was no evidence of a blood dyscrasia.

Perforation of a Gastric Ulcer Associated with Intracranial Hemorrhage in a Newborn Infant

That perforated gastric ulcers are of unusual occurrence in infants and children is well established. In a review of 248 cases of ulceration of the stomach in children, Theile (1, 2) found only 5 instances of perforation. Pendergrass and Booth (3) have also stressed the absolute and relative rarity of this complication in childhood as compared to its incidence in later life. The etiology of ulceration in children, with or without subsequent perforation, is obscure. Adler (4) attributed it to autodigestion occurring as a result of small hemorrhages during parturition. Other causative agents which have been suggested are direct trauma, infection, local disturbance of circulation from congestion, embolism, thrombosis, and vascular disease. The brilliant work of Cushing (5), following that of German investigators (7, 8), established a neurogenic origin for many gastric ulcers. Animal experiments and his observation of multiple ulcers of the stomach, frequently with perforation, following brain surgery, more especially operations in the region of the cerebellum, led him to the conclusion that injury or stimulation in this latter region may lead to the development of peptic ulcer. The establishment of the diagnosis of peptic ulcer in an infant is difficult. The only clinical sign is hemorrhage. According to Hurst and Stewart (9), 50 per cent of cases of melena in infancy are due to peptic ulcer. Roentgen examination should therefore be made, and if necessary repeated at frequent intervals, in any infant with bleeding from the gastro-intestinal tract, in order that an early diagnosis may be made. The following case is believed to be of interest because of the rarity of perforation of gastric ulcer in the newborn, for the association of the condition with intracranial injury, and as illustrating the importance of early roentgen diagnosis. Case Report The patient was a full-term male infant weighing 6 lb. 14 oz., the second child of a Puerto Rican mother. The prenatal course had been normal, and the mother's Mazzini test was negative. Labor pains began at noon, Oct. 9, 1948; the membranes ruptured at 2:30 p.m., and spontaneous delivery occurred at 10:20 p.m. of the same day. The infant was in a vertex presentation, left occiput anterior position. At no time were forceps used, nor was there any undue trauma associated with the birth. The child appeared well until the second day, when he passed two dark red stools and vomited dark brown fluid once. On physical examination he was described as a well nourished, normally developed baby. The skin was pale and free from petechiae. Examination of the head was negative. The chest was clear and the abdomen was soft. Bleeding and clotting times were within normal limits. The white cell count was 5,600, with 86 per cent polymorphonuclears, 10 per cent lymphocytes, and 4 per cent myelocytes; red cell count, 3,320,000; hemoglobin, 11.5 gm.; hematocrit reading, 40. There was no evidence of a blood dyscrasia.

Free perforation of jejunal ulcer

D URING the past forty years, occasionaIIy onIy have reports been made on free perforation of jejunaI uIcer into the peritonea1 cavity. The first case of free perforation of jejunaI uIcer pubIished was that reported by Braunl in 1889. The first EngIish case of peptic uIcer of the jejunum was described by Mayo Robson in 1903. The IiabiIity of the uIcer to perforation was emphasized by ConneII” and by Patterson4 who made the first summary report on perforations of jejuna1 uIcers. In his report he divided the perforations into two types: those that perforate free into the abdomina1 cavity and those that perforate sIowIy and form an abscess or fistuIa. In his report in Igog, he gives us a summary of Ig cases of free perforation of jejuna1 uIcer. In 1918, Wright5 of EngJand coIIected enough cases to bring the number up to 32 and Massie6 of Guy’s HospitaI in 1924 coIIected 5 more cases which brought the number up to 37. Singer and Myer’ were abIe to coIIect and add to Massie’s number, 58 perforations occurring in 49 patients and aIso added 5 cases of their own. This makes a tota of one hundred instances of perforation of jejuna1 uIcers invoIving 86 patients. To this I am abIe to add 2 more cases of free perforation of jejuna1 uIcer. One I have coIIected from the articIe by Woodside. This was a case of 2 perforations successively in a boy tweIve and a haIf years of age, foIIowing a posterior gastroenterostomy. The other case is one of my own, the perforation having occurred fourteen months folIowing posterior gastroenterostomy.