Site Of Perforation Research Articles

Cardiac tamponade complicating ventricular arrhythmia ablation: Real life data on incidence, management, and outcome.

Cardiac tamponade during ablation procedures is a life-threatening complication. While the incidence and management of tamponade in atrial fibrillation ablation have been extensively described, the data on tamponade during ventricular ablations are very limited. The purpose of this study is to shed light on the incidence, typical perforation sites, and optimal management as observed through real-life data in a tertiary referral center for ventricular ablation. Consecutive patients with structural heart disease undergoing ventricular tachycardia ablation from 2008-2020 were analyzed. Of the 1078 patients undergoing 1287 ventricular ablation procedures, 20 procedures (1.5%) were complicated by cardiac tamponade. In all but one patient, the tamponade was treated with emergent pericardial drainage, while nine patients eventually underwent surgical repair. The perforation occurred during transseptal or subxiphoid puncture in six patients, during ventricle mapping in two patients, and during ablation in five patients (predominantly basal left ventricle). Steam pop as definite perforation cause could only be established in two patients. Regardless of the management of the complication, all patients survived to discharge. Cardiac tamponade during ventricular ablation occurred in 1.5% of the procedures. In nine patients cardiac repair was necessary. Perforation was mostly associated with subxiphoid puncture or ablation of the basal left ventricle.

A Comparative Study of Tympanoplasty with or without Mastoidectomy in Tubotympanic Type of Chronic Suppurative Otitis Media

Background: One of the most frequent ear illnesses in underdeveloped countries is chronic suppurative otitis media (CSOM). In the treatment of CSOM, otolaryngologists debate whether to perform tympanoplasty with or without cortical mastoidectomy. Objective: To compare the outcome of tympanoplasty with or without cortical mastoidectomy in the treatment of tubotympanic type chronic suppurative otitis media. Methods: This comparative study was carried out in the Department of Otolaryngology - Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka from July 2017 to June 2019 over a period of 02 years. A total number of 60 patients who underwent type 1 tympanoplasty with or without cortical mastoidectomy were enrolled in this study. After enrollment the condition of the pinna, preauricular region, postauricular region and external auditory cannal were examined. On otoscopy, site and size of perforation of tympanic membrane, condition of the rest of the tympanic membrane, condition of the middle car mucosa and the ossicles were also examined. Tuning fork tests, test for facial nerve integrity and fistula test were performed. Hearing level was assessed by pure tone audiometry with masking. Enrolled patients were grouped into two groups. Patients who underwent type- 1 tympanoplasty alone kept in group A and who underwent type 1 tympanoplasty with cortical mastoidectomy kept in group B. Complete blood count, blood urea, serum creatinine, random sugar, ECG and X-ray chest P/A view were done routinely. Results: Females were 76.7% in group-A and 53.3% in group-B. All patients were of age between 16 to 60 years and most of them were in the age group of 21-30 years. Majority of the patients were from rural area and maximum patients were from middle class family. In most of the patients unilateral ear involvement was observed. Perforation site was central malleolar in maximum cases followed by anterior central and posterior central. Perforation size was ........

Comparative Study of Outcome of Wedge Excision of Perforation Site and Trimming of Perforation Margin Followed by Primary Repair in the Management of Ileal Perforation

Lipomas are benign tumors of adipose tissue consisting of soft, lobulated masses held together with connective tissue and sometimes encapsulated in a thin, fibrous capsule. Lipomas are the most common soft tissue tumor, occurring in 1% of the population. The objective of our study is to present the epidemiological aspects of lipomas in the population of the region of Tangier-Tetouan-Al Hoceima, to determine the etiopathogenic aspects, and to describe the modalities of surgical treatment and especially to make a comparison between the lipectomy and liposuction. This study was carried out retrospectively, by collecting, the sex, and the reason for consultation and the location of the lipomas in the patients admitted to our service, over a period of 12 months from April 2021 to May 2022. The age of our patients ranged from 21 to 46 years. The mean age was 35 years and 3 months. We had 20 (74%) women and 7 (26%) men. The sex-ratio men/women were 0, 35. It must be said that many of our patients consulted because they had noticed an abnormal swelling on one part or another of their bodies. Regarding the management of our patients, only 5 benefited from liposuction while 22 patients benefited from a lipectomy. In all patients, the postoperative follow-up was simple with no early complications.

The influence of tympanic membrane perforation site on the hearing level of conductive hearing loss in chronic suppurative otitis media

Chronic suppurative otitis media (CSOM) is an infection of the middle ear cavity both partially and totally. It is characterized by ear discharge through a tympanic membrane perforation for over a period of 2 to 6 weeks. Hearing loss is the most common complication of CSOM. One of the degrees of hearing loss in tympanic membrane perforation is depending on the site of perforation, but this premise is still debatable because of pros and contras by some researchers. This study aimed to assess the degree of hearing loss in relation to the site of tympanic membrane perforation. A cross-sectional prospective study design was performed involving 43 patients of safe type CSOM who came to the Department of Otolaryngology Head and Neck Surgery from the period January 2016 to November 2018. All subjects were divided into 4 groups based on the site of perforation. There was a perforation in the posteroinferior, the posterosuperior, the anteroinferior, and the anterosuperior. A statistical analysis using Anova along with multivariate analysis was conducted. Our result showed that the most common site of tympanic membrane perforation was at the anteroinferior (30 samples, 59.8%). The highest hearing threshold was seen at posteroinferior with a mean hearing level of 37.7±2.0 dB, anteroinferior with a mean hearing level of 31.7±0.7 dB, anterosuperior with a mean hearing level 30.7±1.4 dB, and posterosuperior mean hearing level 28.9±1.5 dB. The difference was found significant with p=0.004. Posteroinferior tympanic membrane perforation had a higher number of hearing loss compared to the other sites. In conclusion, the tympanic membrane perforation site has an important role in the hearing level of conductive hearing loss in CSOM.

Accuracy evaluation of 3D-printed guide-assisted flapless micro-osteoperforations in the anterior mandible.

To evaluate the accuracy of tridimensional (3D)-printed guide-assisted flapless cortical bone micro-osteoperforations (MOPs) in the anterior mandible on a cadaver model. Five human cadaver heads with complete dentition in the anterior mandible were used in the present study. Preplanning CBCT and intraoral surface scans were obtained. After alignment, drilling sites in the interradicular areas were planned from canine to canine, and a surgical guide was printed. The drilling was performed and a postprocedure CBCT scan was obtained to assess the accuracy of the procedure in relation to the virtual planning. The mean ± standard deviation (SD) mesiodistal interradicular space was 2.67 ± 0.84 mm. The mean ± SD error of the actual drilled hole compared with the planned position of the mesial drill site was 0.66 ± 0.33 mm, and to the distal drill site it was 0.56 ± 0.33 mm. There was a statistically significant difference between the number of times the teeth were hit mesially (10 out of 64 holes) and distally (none). The proposed technique, limited to an ex vivo scenario, provides a valid and reliable method for mandibular MOPs using a 3D-generated surgical guide. However, the risk of damaging adjacent radicular surfaces, particularly in areas with limited mesiodistal interradicular bone, needs to be considered. Further studies should focus on using thinner drills and adding other methods to stabilize the guide. Additionally, by selecting individuals and perforation sites with more mesiodistal interradicular bone, less damage is likely. (Int J Comput Dent 2022;25(4):387-0; doi: 10.3290/j.ijcd.b2599841).

A Case of Multiple Radiation-related Complications during Long-term Follow-up after Sacral Ulcer Surgery

We report the clinical course of a patient who developed a sacral radiation ulcer 19 years after treatment for cervical cancer. The patient's postoperative course after a free latissimus dorsi muscle flap transfer was favorable, but various late radiation complications, including rectal perforation, a rectal fistula, sacral necrosis, a rectointestinal fistula, and sacroiliac joint osteomyelitis, occurred within 11 years. Plastic surgeons who treat such ulcers need to know that patients may develop other serious radiation-related complications. Being aware of these complications will allow appropriate measures to be taken and aid decisions regarding future surgical strategies. More careful assessment of sacral necrosis and bone resection may have ameliorated some of the complications. When encountering similar patients, we believe that careful magnetic resonance imagery (MRI) and intraoperative evaluation are warranted, as sacral necrosis may be detectable in some patients.

Hydraulic fractures evaluation of the glutenite and the effects of gravel heterogeneity based on cores

A demonstration area was established on the north slope of the Mahu Depression, Junggar Basin, NW China to carry out the hydrofracturing experiment and a cored well was designed to investigate hydraulic fractures. 345 fractures, comprising HFs, natural fractures, core-handling fractures, and drilling-induced fractures, were harvested from four continuous cores of about 323.19 m that contained mudstone, sandstone, and conglomerate. The lithology of the core is dominated by the conglomerate, which is characterized by coarse gravel size, poor sorting, and gravel support. Firstly, this paper identifies different fractures by integrating the core observation, imaging logs, and CT scans. The HF in the glutenite reservoir was divided into penetrating-gravel fractures and bypassing-gravel fractures based on the fracture propagation path and fracture surface geometry. Secondly, the occurrence and density of HFs were characterized, respectively. The HF has a dip of 80–90° and two trends of 0°–20° and 160°–220°. The fracture density presents strong heterogeneity over depth and the number of penetrating-gravel fractures is nearly twice of that bypassing-gravel fractures. Besides, no significant proppants were observed on the fracture surface, while it was identified in the rock debris. Thirdly, the gravel size and orientation were selected to investigate the impact of gravel heterogeneity on HFs. The result showed that the larger gravel size and greater acute angle between gravel orientation and HFs propagation orientation are conducive to the development of penetrating-gravel fractures. Finally, the impact of fractured wells on HFs was studied. The fracture density is closely related to the distance between fractures and the perforation site, Cluster spacing, and slickwater. Higher fracture density is a result of closer spacing between HFs and the perforation site, smaller cluster spacing, and a higher percentage of slickwater. The insight of this paper is expected to provide some references for the hydrofracturing operation in oilfields and current experimental and numerical investigation.

Dry versus wet temporalis fascia graft in type-I tympanoplasty: a systematic review and meta-analysis of randomized controlled trials.

To conduct a systematic review and meta-analysis of all randomized controlled trials (RCTs) that examined the efficacy of dry versus wet temporalis fascia graft among patients undergoing type-I tympanoplasty. Web of Science, Scopus, PubMed, and CENTRAL databases were screened from inception until July 2022. The Cochrane risk of bias tool was used to assess the quality of included RCTs. The outcomes were summarized as risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) in a random-effects model. Eight RCTs with 989 patients (dry group = 514 and wet group = 475) were included. The overall quality was 'low', 'some concerns', and 'high' risk of bias in five, two, and one RCT(s), respectively. There were no significant differences between both groups regarding the surgical success rate (n = 8 RCTs, RR 0.99, 95% CI [0.95, 1.03], p = 0.6), audiological success rate (n = 5 RCTs, RR = 0.93, 95% CI [0.73, 1.13], p = 0.48), mean difference in pure tone average (n = 2 RCTs, MD = 2.73Hz, 95% CI [- 2.31, 7.77], p = 0.29), and mean difference in graft placement time (n = 3 RCTs, MD = - 2.18min, 95% CI [- 5.11, 0.76], p = 0.15). However, the mean difference in operative time was significantly lower in favor of the wet compared with the dry temporalis fascia group (n = 2 RCTs, MD = 2.95min, 95% CI [- 1.80, 4.11], p < 0.001). The surgical success rate was not significantly different between both groups according to the tympanic membrane perforation size and site. The type of temporalis fascia graft (dry or wet) did not influence the clinical outcomes of type-I tympanoplasty.

Abstract 12133: Coronary Artery Perforation During Chronic Total Occlusion Percutaneous Coronary Intervention: Incidence, Mechanisms, Treatment and Outcomes

Introduction: Coronary artery perforation is a feared complication of chronic total occlusion (CTO) percutaneous coronary intervention (PCI). Methods: We analyzed the baseline clinical and angiographic characteristics and procedural outcomes of 10,454 CTO PCIs performed in 10,219 patients between 2012 and 2022. Results: The incidence of coronary perforation was 4.9% (n=503). Patients who experienced coronary perforation were older and were more likely to have had prior coronary artery bypass graft surgery. Procedures that resulted in perforation were more complex, with higher J-CTO and PROGRESS-CTO scores. Technical (66% vs. 87%; p&lt;0.01) and procedural (55% vs. 87%; p&lt;0.01) success rates were lower among perforation cases. The most common site of perforation was the CTO target vessel (66%), the retrograde approach was responsible for the perforation in 47% of the cases and guidewire exit was the most common mechanism of perforation. The proportion of Ellis Class 1, 2, 3 and 3 -“cavity spilling” coronary perforations was 20%, 41%, 28% and 11%, respectively. In 52% of perforations, one or more interventions were required: prolonged balloon inflation (23%), covered stent deployment (21%), coil embolization (6%) and/or autologous fat embolization (4%). Tamponade requiring pericardiocentesis occurred in 69 patients (14%). The incidence of major adverse cardiovascular events (MACE) was higher in perforation cases (18.1% vs. 1.3%; p&lt;0.01). Conclusions: Coronary artery perforation occurred in 4.9% of CTO PCIs performed by experienced operators and was associated with lower technical success and higher in-hospital MACE.

Serial observation of PK Papyrus covered stent implantation for coronary artery perforation by optical coherence tomography and coronary angioscopy: a case report

Abstract Background Coronary artery perforation is a rare but life-threatening complication of percutaneous coronary intervention. We present a case of coronary artery perforation treated with a PK Papyrus covered stent. Neointimal coverage evaluation was performed using optical coherence tomography (OCT) and coronary angioscopy (CAS) at 3 and 9 months after stent implantation. Case summary A 63-year-old man was admitted to our hospital with worsening effort angina over 3 months. Coronary angiography revealed severe stenosis in the proximal segment of the left anterior descending artery. After stent implantation, coronary artery perforation occurred. We immediately sealed the perforation site using a PK Papyrus covered stent. The patient was discharged on postoperative day 4. OCT and CAS revealed incomplete neointimal coverage at the PK Papyrus covered stent strut 3 months after stent implantation. At 9 postoperative months, complete neointimal coverage was observed. We continued clopidogrel and edoxaban, but no clinical adverse events were encountered during the follow-up. Discussion To the best of our knowledge, this is the first report of a serial observation of PK Papyrus covered stent implantation for coronary artery perforation using OCT and CAS. In this case, OCT and CAS revealed complete neointimal coverage, without obvious thrombus, 9 months after PK Papyrus implantation. Based on the OCT and CAS findings, our report presents an appropriate follow-up strategy for the prevention of stent thrombosis when using a PK Papyrus covered stent, which will contribute to future research on the appropriate duration of dual antiplatelet therapy and evaluation of neointimal coverage.

Prognostic factors of hearing outcome in patients with chronic suppurative otitis media following tympanoplasty: a retrospective cohort study.

Research on the factors affecting the functional outcome of tympanoplasty in chronic suppurative otitis media (CSOM) is limited. This study aimed to investigate the prognostic factors of hearing outcome in CSOM patients following tympanoplasty. The multivariate logistic regression analysis is used to evaluate the influence of demographic, audiological, clinical and disease factors on the postoperative prognosis of CSOM. A total of 179 CSOM patients who received surgery between January 2016 and December 2019 were retrospectively included. The inclusion criteria are mainly based on clinical classification of otitis media and surgical classification guidelines [2012]. These patients were divided into an effective group (n=132) and a non-effective group (n=47) according to their postoperative air-bone gap (ABG) value. Multivariate analysis was performed according to the pure tone hearing results 1 week before operation and 4 weeks after operation. The type of preoperative hearing impairment, middle ear cholesteatoma, ossicular chain status, tympanic perforation site, repair material, tympanum sclerosis, and surgical methods were significantly different between the effective and non-effective groups (all P<0.01). The speech reception threshold (SRT) (36.88±15.54 vs. 27.68±13.75, P<0.001) and ABG (18.53±9.30 vs. 10.89±5.07, P<0.001) values were markedly reduced after surgery in the effective group but not in the non-effective group. Furthermore, the postoperative decreases in the SRT (9.20±9.69 vs. 2.021±7.34, P<0.001) and ABG (7.64±8.57 vs. 0.45±7.322, P<0.001) values were considerably higher in the effective group than the non-effective group. After multivariate logistic regression analysis, we found that the type of preoperative hearing impairment [P=0.031; odds ratio (OR) =2.378], ossicular chain status (P=0.002; OR =4.430). Our research shows that the curative effect of conductive deafness before operation is 2.378 times better than that of mixed deafness, the curative effect of complete and unfixed ossicular chain before operation is 1.080 times better than that of interrupted ossicular chain, and the curative effect of complete ossicular chain but fixed ossicular chain is 4.430 times better than that of interrupted ossicular chain. Our findings may help to predict the postoperative prognosis of patients, thus facilitating the development of corresponding treatment strategies.

Surgical Audit of Leakage after Open Surgical Repair of Perforated Peptic Ulcer

Objective: to critically analyze the leakage after open surgical repair of peptic ulcer perforation. Methods: All patients who fulfilled the inclusion criteria and visited to surgical department SMBBMU, Larkana from September, 2018 to March, 2021 were included in the study. Informed consent was taken after explaining the procedure, risks and benefits of the study. X-ray abdomen erect posture, leukocyte count, and serum amylase were performed. After surgery, site of perforation and type of surgery were recorded. Patients were followed for 30 days in order to assess the leakage. Results: Mean ± SD of age was 42.6±8.5 years. Out of 203 patients included in the study, 145 (71.4%) were male while 58 (28.6%) were female, Leakage was noted in 13 (6.4%) patients. Conclusion: It is to be concluded that leakage was less likely prevalent after peptic ulcer perforation repair, but we cannot rule out residual confounders. Practical implication Keywords: Leakage, Peptic Ulcer Perforation, Repair, Peritonitis, Laparoscopy, Surgery.

Perforation peritonitis: as a spectrum

Background: Peritonitis due to hollow viscus perforation is one of the frequent cause of patient presenting as acute abdomen in clinical practice. The cause of this perforation can be traumatic perforation or an underlying diseased viscus.Methos: The study was conducted in Sir J J group of hospitals, Mumbai between January 2021 to June 2021. A total of 50 cases with peritonitis due to gastrointestinal tract perforation were studied. The patient were studied on the basis of clinical presentation, radiological findings, cause and site of perforation, treatment given, postoperative complication and mortality.Results: Perforated duodenal ulcer (32%) and illeal perforation (24%) were most common in our study which is in contrast to the pattern seen in western part of the world. Perforations due to malignancy were the least commonly seen.Conclusions: As indicated on our study the spectrum of perforation peritonitis in India continues to be different from its western counterpart with duodenal ulcer perforation, perforating appendicitis, typhoid perforation and tubercular perforation being the major causes of generalized peritonitis.

Hearing loss increases with size but not site of tympanic membrane perforation in Aboriginal Australian children in remote locations.

To investigate the effect of size, site, and activity of tympanic membrane (TM) perforation on hearing loss (HL) in Aboriginal and Torres Strait Islander (ATSI) children. Observational study. Children aged 5-18 years who identified as ATSI at seven Anangu community schools within the Anangu Pitjantjatjara Yankunytjatjara Lands and Maralinga Lands of South Australia underwent 4-frequency pure-tone audiometry (0.5, 1, 2, and 4kHz) and video-otoscopy (VO). VO data was reviewed by surgeons for a middle ear diagnosis and VO files with TM perforations were then classified by perforation site (AS, AI, PS, PI, A, P, I) and size (<25%, 25%-50%, 50%-75%, or 75%-100%). Five hundred seventy-five VO files with matching audiological data were obtained. Active perforations (35 dBHL; 28-44 IQR) demonstrated greater HL than inactive perforations (31 dBHL; 29-39 IQR) p=.0029. For inactive perforations there was a significant difference between <25% and all larger perforations (p < .0001) whereas for active perforations the significance changed to between <25% (p < .0001) and 25%-50% (p < .05) when compared to larger perforations. When perforation site was compared within all size/activity groups, no statistically different findings were identified. In all analyses, findings did not change when individual frequencies were compared to 4-frequency pure-tone average dBHL. In ATSI children from remote communities, HL is greater in ears with larger perforations and active middle ear disease but there was no relationship between perforation site and HL.Level of evidence: Level 4.

Correlation of Hearing Loss with the Site and Size of Tympanic Membrane Perforation

Objectives: This study was done to observe the relation of hearing loss with the site and size of tympanic membrane perforation. Methods: It was a prospective type of Observational study which was conducted at the Department of Otolaryngology and Head Neck Surgery, Uttara Adhunik Medical College Hospital, Dhaka during the period of May 2012 to October 2012 on patients that attended the outpatient department and also who were admitted in otolaryngology and head-neck surgery department. Total 200 patients (between 14 to 50 years of age) with perforated tympanic membrane in pars tensa were included by non-randomized purposive sampling. Among these patients 108 were male and 92 were female. They were categorized according to site and size of tympanic membrane perforation. Hearing threshold was assessed by pure tone audiometry. Results: According to size, there were small 44 (22%), medium 65 (32.5%), large 48 (24%) and subtotal /big central 43 (21.5%) perforations. According to location, there were anterior central 28 (14%), posterior central 35 (17.5%), central malleolar 94 (47.0%) and big central/subtotal 43 (21.5%) perforations. It was found that subtotal/big central perforations with the average bone conduction threshold 17.40 ±10.62 dB (SD), air conduction threshold 46.95 ±12.89 dB and air- bone gap 29.56 ± 5.85 dB caused more hearing loss than small and medium sized perforations. So it was seen that larger the perforation, more the hearing loss. Anterior central perforation had average bone conduction threshold 13.03 ± 3.61 dB, air conduction threshold 33.48 ± 4.81 dB and air-bone gap 20.86 ± 3.73 dB. Posterior central perforation had average bone conduction threshold 15.44 ± 7.38 dB, air conduction threshold 40.64 ± 10.34 dB and air-bone gap 25.11 ± 6.42 dB. This difference represent that posterior central perforation causes more hearing loss than that of anterior central. Hearing loss is also related to duration of perforation. Perforation for 0-5 years with ....

Influence of neurovascular anatomy on perforation site in different mouse strains using the filament perforation model for induction of subarachnoid hemorrhage.

BackgroundFilament perforation is a widely-used method to induce subarachnoid hemorrhage (SAH) in mice. Whereas the perforation site has been assumed to be in the branching of middle cerebral artery (MCA) and anterior cerebral artery (ACA), we recently observed more proximal perforations.MethodsFilament perforation was performed in CD1- (n = 10) and C57Bl/6N-mice (n = 9) ex vivo. The filament was left in place and the perforation site was microscopically assessed. Digital subtraction angiography (DSA) was performed in CD1- (n = 9) and C57Bl/6J-mice (n = 29) and anatomical differences of the internal carotid artery (ICA) were determined.ResultsWhereas in C57Bl/6N-mice perforation occurred in the proximal intracranial ICA in 89% (n = 8), in CD1-mice the perforation site was in the proximal ICA in 50% (n = 5), in the branching between MCA and ACA in 40% (n = 4), and in the proximal ACA in 10% (n = 1). DSA revealed a stronger angulation (p<0.001) of the ICA in CD1-mice (163.5±2.81°) compared to C57Bl/6J-mice (124.5±5.49°). Body weight and ICA-angle showed no significant correlation in C57Bl/6J- (r = -0.06, pweight/angle = 0.757) and CD1-mice (r = -0.468, pweight/angle = 0.242).ConclusionFilament perforation in mice occurs not only at the hitherto presumed branching between MCA and ACA, but seems to depend on mouse strain and anatomy as the proximal intracranial ICA may also be perforated frequently.

Relationship between size and site of tympanic membrane perforations and pure tone audiometry results

Background: Chronic otitis media is a condition commonly presenting with tympanic membrane perforation and resulting in conductive hearing loss. The aim of the study was to assess the relationship between the site and size of tympanic membrane perforation with the degree of hearing impairment in patients with inactive chronic otitis media of mucosal type. Methods: Hospital based cross sectional study of 174 patients with tympanic membrane perforation at government medical college, Alappuzha from November 2017 to March 2019. Patients were enrolled based on history and clinical examination findings. Images obtained by otoendoscopy were analyzed by measuring the percentage area of membrane perforation in relation to total area of the tympanic membrane using adobe acrobat area tool. Degree of hearing loss was calculated by pure tone audiometry test and calculating the average hearing thresholds at frequencies of 500Hz, 1000Hz, 2000Hz and 4000Hz. Results: The age distribution of patients ranged from 14 to 72 years with a mean age of 41.78years. Male to female ratio was 1.59:1. The degree of hearing loss increased as the size of the perforation increased which was statistically significant (p &lt;0.001). Posterior quadrant perforations resulted in more hearing impairment than anterior quadrant perforations. Conclusion: The size of the tympanic membrane perforation is closely related to the degree of hearing loss and posterior quadrant perforations have more degree of hearing impairment than anterior quadrant perforations which signifies improvement in hearing in patients with chronic otitis media by reconstructive surgeries, especially for perforations involving the posterior quadrant.

Rapunzel Syndrome: A Case of Trichobezoar with Small Bowel Complications

Introduction Rapunzel syndrome is characterized by a large trichobezoar in the stomach with a tail extending beyond the pylorus into the small bowel, causing mechanical obstruction of the small bowel. A 7-year-old girl presented to the emergency room with severe epigastric pain. Computed tomography suggested trichobezoar causing jejuno-jejunal intussusceptions, bowel wall thickening, and dilated small bowel loops proximal to the obstruction. On laparotomy, two concealed perforations were noted at the duodenojejunal (DJ) junction and 40 cm distal to the DJ junction. An enterotomy incision was given at the antimesenteric border of the distal jejunal perforation site, and the mass was successfully extracted. Primary repair was done at the DJ perforation site, and resection was followed by an end-to-end anastomosis at the distal jejunal perforation site. Surgery confirmed a complex mass of tangled hair within the gastric cavity with a tail extending into the pylorus of the stomach and small intestine, consistent with trichobezoar. Conclusion Computed tomography is superior to other radiological imaging modalities for diagnosing trichobezoars as it helps diagnose and demonstrate mechanical bowel complications.

S2167 Chronic, Massive Pneumoperitoneum in a Patient Without Signs of Peritonitis: A Case Report

Introduction: Pneumoperitoneum is the presence of free air in the abdominal cavity. This alarming symptom can be due to a wide variety of etiologies, including infection, trauma, perforation, and others. However, pneumatosis intestinalis, which is the presence of free air in the extraluminal space, can be due to other pathology unrelated to the GI tract. It can be seen in pulmonary disease, such as COPD and asthma, autoimmune conditions, and drug-induced causes as well. It can present with more benign symptoms. We present a case of chronic pneumatosis intestinalis that was present in the patient for over 2 years and presented with relatively minor, nonspecific symptoms. Case Description/Methods: This patient was a 62-year-old male who presented with concerns of bloating and cramping, ongoing for 2 years. Previous work-ups had not revealed a clear cause for his ongoing symptoms. He had undergone CT of the abdomen, which was significant for massive pneumoperitoneum, as well as fluid-filled prominent loops of small bowel concerning for ileus or obstruction. There was no site of bowel perforation that could be visualized. Upper endoscopy and colonoscopy had been performed, which showed normal mucosa and colonic diverticulosis. After further workup at an additional institution, diagnostic laparotomy was recommended to further evaluate his small bowel. At the lower anterior diaphragm, the peritoneal surface had subperitoneal emphysema, suggesting a potential thoracic source for the pneumoperitoneum. Thoracic surgery were consulted for exploratory right-sided thoracoscopy since he was noted to have peritoneal blebs along the diaphragm most notably, with one also being identified on the liver. It was concluded that the etiology was most likely due to an alveolar-peritoneal fistula through the right hemidiaphragm (Figure). Discussion: Pneumatosis Intestinalis can be a benign presenting symptom. Pneumoperitoneum can be due to primary (idiopathic) or secondary causes. Secondary causes are numerous, and these can be seen in the setting of COPD, immunodeficiency, or acute GI pathology. Increased pressure in the abdomen or the mediastinum can result in gas diffusing across tissues and into the bowel wall. Treatment and management varies depending on the patient's presentation. More serious abdominal pathology requires surgical management, while benign causes in the setting of chronic lung pathology can be asymptomatic, or present with mild symptoms that require only conservative medical management.Figure 1.: Pneumatosis Intestinalis on CT Scan.

Intraoperative optical coherence tomography-guided donor corneal tissue assessment and preparation.

To evaluate the role of intraoperative optical coherence tomography (i-OCT) in donor grading, selection, and preparation during different types of keratoplasty. Seventy-one consecutive donor corneas collected over 6 months, after clinical grading, were observed by an experienced corneal surgeon under an i-OCT equipped microscope. The donor preparation (manual/automated) for different types of keratoplasty procedures was also undertaken under i-OCT. The mean central corneal thickness of optical and nonoptical grade tissues was 533 ± 19 and 662 ± 52 μm, respectively. The i-OCT-based grading matched with clinical grading in 98.5% cases. Irregular thickness, anterior stromal hyperreflectivity, and previous scars were appreciated in 1.4, 1.4, and 7.04% donors, respectively. During Descemet stripping automated endothelial keratoplasty, i-OCT facilitated selection of appropriate microkeratome head for automated donor preparation in all cases, besides allowing manual dissection of partially dissected lenticule, identification of site of inadvertent perforation, and eccentric trephination in one case each. During Descemet membrane endothelial keratoplasty, i-OCT-based assessment of preexisting scar (five cases) guided careful tissue selection (2/5) and preparation. During predescemetic endothelial keratoplasty, precise needle advancement allowed successful type-1 bubble formation in all cases. All manually punched donors demonstrated an extra endothelial ledge, while those with automated preparation showed tapering donor margins. i-OCT might serve as a useful imaging tool for objective assessment of donor characteristics. The modality may complement clinical evaluation for donor grading, selection, and preparation.