Small Perforation Research Articles

Cessation of methotrexate and a small intestinal resection provide a good clinical course for a patient with a jejunum perforation induced by a methotrexate-associated lymphoproliferative disorder: a case report

BackgroundMethotrexate (MTX) is a frequently used drug in the treatment of rheumatoid arthritis (RA), but occurrences of lymphoproliferative disorders (LPD) have been reported in patients undergoing an MTX regimen. Almost half of the patients with methotrexate-associated lymphoproliferative disorders (MTX-LPD) have extranodal lesions; moreover, although extremely rare, digestive tract perforations resulting from the extranodal lesions of MTX-LPD have also been reported.Case presentationWe describe the case of an 81-year-old woman with RA who had been prescribed MTX at 6 mg per week for the past 11 years. She was admitted to our hospital with occasional abdominal pain and was first diagnosed with enteritis. Her abdominal pain did not improve, and a computed tomography scan showed abdominal effusion and free air in the abdominal cavity. She was diagnosed with a digestive tract perforation and underwent emergency surgery. The perforation site was identified in the jejunum, and she underwent small intestinal resection around the perforated region. The pathological findings showed an ulcer in the jejunum and infiltration of large atypical lymphocytes around the perforated region. An immunohistochemical examination revealed the expression of a cluster of differentiation 20 and latent membrane protein 1. Considering the patient’s history of RA treated with MTX, she was diagnosed as having Epstein–Barr virus (EBV)-related MTX-LPD with a histological diagnosis of EBVMCU. MTX was discontinued after the surgery, and her soluble interleukin-2 receptor (sIL-2R) levels had returned to normal 1 year later. She has had a good course for the 2 years since surgery and remains asymptomatic with no recurrence of MTX-LPD, as confirmed by the sIL-2R levels.ConclusionWe experienced a rare case of the jejunum perforation induced by MTX-LPD. Since only a few cases have been reported of a patient with small intestinal perforation induced by MTX-LPD, further research is necessary to evaluate the clinicopathological features of MTX-LPD. The patient had disease remission after surgery and by discontinuing MTX treatment; our case did not require chemotherapy. EBV-positive patients, especially those with a pathological presentation of EBVMCU, could have a higher likelihood of remission, which could have been a factor in the present case.

Management outcome of non-traumatic small intestinal perforation: A prospective study

Background: Small intestinal perforation peritonitis is a surgical emergency which remained a challenge to the surgeons since time immemorial. Independent of its aetiology all the cases of small intestinal perforation have similar clinical features leading to peritonitis with fulminating secondary bacterial infection for which the condition is studied as one entity.Material and Methods: A prospective study of 40 patients presenting to VSSIMAR, Burla with a diagnosis of Small bowel perforation between November 2017 and October 2019 was done. The history, clinical features, the investigations done, the surgical procedure performed, the post-operative ICU care, the complications, the secondary procedures undertaken and mortality rate were recorded.Results: The maximum number of cases were in the age group of 21-30yrs (32.5 %) followed by 31- 40yrs (25 %) with a male to female ratio 7:3. Pain abdomen was the most common symptom. Majority of patients (42.5%) were presented between 24-48 hrs. The most common abdominal findings were guarding / rigidity, abdominal distension each 95%, free gas under diaphragm found in 90% of cases. Widal test was positive in 35% cases. 8 cases (20%) didn’t respond to fluid therapy alone and required vasopressors. 85% were ileal perforation, 15% were jejunal perforation. Simple closure with drainage was the most performed procedure (65% of cases). Typhoid & nonspecific inflammation tops the aetiology (35% each) followed by Tuberculosis (22.5%). The most common complication was wound infection in 14 cases (35%). Seven patients who required critical care and later on also secondary procedure were stayed longest with mean 26.28 days and range 19-36 days. The overall mortality rate was 10%. Elderly (p

A study on fat plug myringoplasty for small tympanic membrane perforation

Introduction: Fat plug myringoplasty is an under-used technique to repair a small central tympanic membrane perforation. It is easy, quick and cost effective way with minimal morbidity. It can be done as an OPD procedure. The fat is readily available from ear lobe, abdomen and buttocks. Fat graft myringoplasty (FGM) is a noninvasive, but underused surgery for perforations of the tympanic membrane. It is also preferable for use in children. Fat tissue has been used as an autogenous material for different surgeries and is known to have a high capacity for resistance. Our study is conducted to evaluate the effectiveness of using fat plug in small central tympanic membrane perforation.Aim: To evaluate the effectiveness of using fat plug in small central tympanic membrane perforation.Materials and Methods: This study was conducted in the ENT department of Sree Mookambika Institute of Medical Sciences, Kulasekharam, Kanyakumari district in a time period from JUNE 2020 to November 2020.The sample size was taken as 30 patients who had presented with complaints of ear discharge, and hearing loss, surgical procedure was done where a fat graft was inserted through the perforation for those patients who fulfilled the inclusion criteria. The study was conducted after obtaining the clearance from Institutional Human Ethical Committee.Study Design: Prospective descriptive study.Results and analysis: 30 patients were included in the study. Age range, 20 to 80 years with a tympanic perforation (size, up to one-quarter of the pars tensa). Out of which 24 % had graft failure due to variety of causes. Success rate was 76% in our study, where as the study conducted by Ringenberg et al. The success rate was 86.5%. Posterior perforations had an overall closure rate of 63%, and in anterior perforations, the overall closure rate was 36%.Conclusion: In conclusion it is simple, safe, quick, economical procedure done under local anesthesia with as success rate as temporalis fascia and minimal or no morbidity and complications. The failure rate in our study was 24% due to infection, detached fat graft and dehiscence due to undersized grafts. Posterior perforations had an overall closure rate of 63%, and in anterior perforations, the overall closure rate was 36%. Pure tone audiometry was used to assess average AB gap pre and post operatively. Postoperatively there was an improvement in hearing compared to preoperative hearing.

Endoscopic Tympanoplasty: Inlay Cartilage Versus Underlay Cartilage Graft

Aim: Several graft placement methods have been described in tympanoplasty. The aim of this study is to assess the surgical effects of the endoscopic tympanoplasty utilizing inlay cartilage or underlay cartilage graft. Methods: We reviewed medical records of 123 patients who experienced endoscopic tympanoplasty for chronic otitis media with a minimum twelve-month follow-up period. Perforations were divided into central, posterior, and anterior ones based on the place of the perforation to malleus handle. Graft success rate, air conduction pure tone audiometry (PTA) before surgery and after surgery, hearing gain and air bone gap (ABG) reduction were calculated following surgery. Results: No significant difference was found between the groups in terms of the distribution of the follow-up period, age, perforation location, and gender (p>0.05). The average air conductions (AC) before surgery and after surgery for the inlay group were 36.3 ± 13.7 dB and 25.4 ± 12.3 dB 6 months after surgery and 22.5 ± 10.5 dB 12 months after surgery. They were 35.6 ± 13.3 dB and 24.8 ± 12.4 dB 6 months after surgery and 22.7 ± 9.7 12 months after surgery for the underlay group. A significant difference was found between the two groups in terms of ABG (P=0.037). There was no significant difference in the mean ABG in each group (small perforation P =0.473, medium perforation P=0.876 and large perforation P=0.341). Conclusion: The inlay method can be used with high graft success rate, low risk of complications among the appropriate patients, and shorter operation time as a reliable surgical option for treatment.

A study on chemical cauterisation for small tympanic membrane perforation

To study the effectiveness of chemical cautery with patching on chronic tympanic membrane perforations of the pars tensa. Thirty-eight patients with dry tympanic membrane perforations due to inflammatory or traumatic etiology were selected after treating the primary etiological factors like septal deviation and allergic rhinitis. Fifty percentage silver nitrate was used to cauterize the margin and the perforation was covered with thin sterile aluminium foil as a patch. A maximum number of five applications were made, and the patients were followed up for the next 5 years. In this series of 38 patients, highest success was noted among those patients with traumatic perforation, while larger perforations were reduced to small pinhole sizes which were successfully closed by myringoplasty. An overall success rate of 73.75% was achieved. This is a time tested useful method which was popularized by Derlacki (1953), to close small to moderate sized tympanic membrane perforation and should be considered as a first line management in the treatment of tympanic membrane perforation prior to any surgical intervention. Apart from being a simple and economical mode of treatment, it is associated with minimal complications. Though various materials have been used to modify this technique, the principle remains the same and the results obtained in this study is comparable with the previous ones.

A Case of Small Intestinal Perforation by a Fish Bone in an Incarcerated Inguinal Hernia

A Case of Small Intestinal Perforation by a Fish Bone in an Incarcerated Inguinal Hernia

Effect of Strict Lockdown on Pediatric Surgical Services and Residency Programme during COVID-19 Pandemic

OBJECTIVE: To document the measures adopted during the COVID-19 pandemic strict lockdown on pediatric surgical services and residents' training at a tertiary care hospital. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: Department of Pediatric Surgery, National Institute of Child Health, Jinnah Sindh Medical University, Karachi, from April 2020 to June 2020. METHODOLOGY: Data from the Outpatient Department, Emergency Department, and Operation Theatre records were collected. The number of patients seen in the outpatient department, surgeries performed, index emergency cases dealt with, and the residents' duty roster and teaching methodology were documented. Descriptive statistics were used for reporting. RESULTS: During the strict lockdown period, outpatient services continued;however, elective cases were not operated. A total of 2,930 patients were seen in clinics, and 1,316 surgical procedures were performed. The index cases managed included anorectal malformation (n=35), esophageal atresia with and without tracheoesophageal fistula (n=13), small bowel atresia (n=11), omphalocele (n=6), acute appendicitis (n=35), intestinal obstructions (n=23), intussusceptions (n=18), and intestinal perforations (n=16). On-call days of residents were reduced from every third to the fifth day, and online educational sessions were added. During the pandemic, 13 members of surgical and anaesthesia teams got infected with COVID-19. CONCLUSION: COVID-19 pandemic elective surgical services were restricted;however, emergency cases were managed as per routine. In clinical teaching, virtual technologies were incorporated. Working hours of residents were limited to decrease the exposure to infected persons. Key Words: COVID-19, SARS-CoV-2 pandemic, Healthcare workers, Residency programme.

Development of an <i> in-situ</i> Printing System with Human Platelet Lysate Based Bioink to Treat Corneal Perforation

Purpose: Corneal perforation is a clinical emergency. Tissue glue to seal the perforation, and supplementary topical medication represents existing standard treatment. Previously, our group developed a transparent bioink that showed good cell compatibility and accelerated corneal epithelial cells healing in-vitro. This study aims to develop a novel treatment method for corneal perforation using this bioink. Methods: Rheometry was used to measure bioink behaviour at room and corneal surface temperatures. Bioink adhesiveness to porcine skin and burst pressure limit were also measured. Based on rheological behaviour, a hand-held biopen was developed to extrude the bioink onto the cornea. An animal trial (5 New Zealand white rabbits) to compare bioink and cyanoacrylate glue (control group) impact on a 2mm perforation was conducted to evaluate safety and efficacy. Results: Bioink has higher adhesiveness compared to commercial fibrin glue and can withstand burst pressure approximately 6.4x higher than routine intraocular pressure. Bioink-treated rabbits had lower pain score and faster recovery, despite generating similar scar-forming structure after healing compared to controls. No secondary corneal ulcer was generated in rabbits treated with bioink. Conclusions: This study reports a novel in-situ printing system capable of delivering a transparent bioink to the cornea and successfully treating small corneal perforations. Bioink-treated rabbits recovered faster to completely healed perforation and required no additional analgesia. Both groups showed scarred corneal tissue after healing, however no infection and inflammation was observed 3 weeks. The delivery system was easy to use and may represent an alternative treatment for corneal perforation. Funding Information: We acknowledge the funding support from Australian Research Council (ARC) Centre of Excellence Scheme (CE140100012), Sydney Eye Hospital Foundation and NSW Medical Device Fund. The hPL used within the study was a gift from Australia Red Cross. Declaration of Interests: J. You (P), iFix Medical (I,F); H. Frazer (P); S. Sayyar, None; Z. Chen, None; X. Liu, None; A. Taylor, None; B. Filippi, None; S. Beirne, None; I. Wise, None; C. Hodge, None; G. Wallace, None; G. Sutton (P), iFix Medical (I). Ethics Approval Statement: Human corneas not meeting transplantation quality requirements were obtained from New South Wales Organ & Tissue Donation Service (Human Research Ethics Committee approval 14/275). The trial was conducted at the University of Sydney Charles Perkins Centre Laboratory Animal House Facility with Animal Ethics Committee approval (AEC: 2018/1317).

Aftermath of traumatic tympanic membrane perforation: Our findings at a tertiary care hospital in Pakistan.

Objectives:To determine the outcome of traumatic tympanic membrane perforation in a teaching hospital at Peshawar, Pakistan.Methods:This prospective observational study was performed in the Department of ENT and Head and Neck Surgery, MTI/LRH, Peshawar, Pakistan from January 2016 to December 2019 after approved from Institutional Research and Ethical Board. All consented patients fulfilling inclusion criteria were enrolled. Sample size was calculated 114 using online sample size calculator (OpenEpi). Every patient was evaluated properly, subsequently otoscopy and PTA was performed. Required information was recorded and analyzed using SPSS (version 25).Results:Out of 114 patients 81 (71.1%) were males and 33(28.9%) were female with male: female ratio of 2.5:1. Patient’s age ranged from 6- 55 years with mean ± SD age of 26.41 ± 9.7 years. Majority of Patients, 46.5%( 53) were in 2nd decade. Amongst the causes slap outnumbered (80, 70.2%), and left ear was involved predominately (67, 58.7%) affecting mainly anterio-inferior quadrant (50, 43.9%). Small size perforation was most common finding (64, 56.1%). Majority of patients (72, 63.2%) presented in a week time and single perforation was the commonest (107, 93.%). Most of traumatic TM perforation got healed spontaneously (97, 85.1%).Conclusion:It is concluded that spontaneous healing of traumatic membrane perforation occurs in more than 90% cases provided the ear is kept dry and not accompanied by unfavorable conditions.

A Case of Small Intestinal Perforation Sustained in a Personal Watercraft Accident

A Case of Small Intestinal Perforation Sustained in a Personal Watercraft Accident

Abdominal gastrointestinal imaging findings on computed tomography in patients with COVID-19 and correlation with clinical outcomes

PurposePulmonary imaging finding of Coronavirus disease 2019 (COVID-19) has been widely described, but until now few studies have been published about abdominal radiological presentation. The aim of this study was to provide an overview of abdominal imaging findings in patients with COVID-19 in a multicenter study and correlate them with worse clinical outcomes. Materials and methodsThis retrospective study included adult COVID-positive patients with abdominal CT performed from 4/1/2020 to 5/1/2020 from two institutions. Demographic, laboratory and clinical data were recorded, including clinical outcomes. ResultsOf 81 COVID-positive patients, the average age was 61 years, 42 (52%) women and 45 (55%) had positive abdominopelvic findings. The most common abdominal imaging features were intestinal imaging findings (20/81, 24%), including colorectal (4/81, 5%) and small bowel thickening (10/81, 12%), intestinal distension (15/81, 18%), pneumatosis (1/81, 1%) and intestinal perforation (1/81, 1%). On multivariate analysis, intestinal imaging findings were associated with higher risk of worse outcome (death or invasive mechanical ventilation) (RR = 2.6, p = 0.04) and higher risk of invasive mechanical ventilation alone (RR = 6.2, p = 0.05). ConclusionIntestinal abnormalities were common findings in COVID-19 patients who underwent abdominal CT and were significantly correlated to worse outcomes in the clinical follow-up.

How Do We Perform Imaging Tests before Treating Cerebral Aneurysms?

Acquiring appropriate preoperative images is an important step in the treatment of cerebral aneurysms. Despite recent advances in contrast-enhanced CT and MRI, catheter angiography remains the standard of care in preoperative imaging tests for both ruptured and unruptured intracranial aneurysms. Three-dimensional rotational angiography can provide a clear view of vascular structure around the aneurysm in an intuitive manner, including the small perforators. For ruptured aneurysms, the treatment modality(i.e., surgical clipping or endovascular embolization)is usually based on emergent contrast CT and catheter angiography findings. For unruptured aneurysms, integrated assessment involving CT, MRI, and angiography is often useful in multimodal treatment decision making.

Effectiveness of underlay myringoplasty in inactive mucosal chronic otitis media; a prospective study

Introduction: Patients with a mucosal type of chronic otitis media (COM) usually have recurrent ear discharge and conductive hearing loss. It is characterized by the central perforation of the tympanic membrane. Myringoplasty is an operation performed to repair tympanic membrane perforation when there is no ossicular damage. It helps to prevent ear discharge and improves hearing. Different techniques used for myringoplasty are underlay and overlay. Underlay technique is an effective procedure for tympanic membrane repair. Methods: 125 patients who underwent underlay myringoplasty over two years in a tertiary care center in Kerala were included in the study. Patients with actively discharging ears were excluded from the study. Results: The majority of the patients were in the age group of 20-29 years (49.6%). There were 47 males (37.6%) and 78 females (62.4%). In 63 patients the surgery was done on the right side (50.4%) and in 62 patients on the left side (49.6%). Maximum preoperative hearing loss was in the range of 30-34 dB (39.2%). 100 patients (80%) showed successful graft uptake with the improvement of hearing in the range of 10-15 dB. Eight patients (6.4%) showed small residual perforation with the improvement of hearing. In 17 patients (13.6%) there was a complete rejection of graft with continuous ear discharge and no improvement in hearing. Conclusion: Underlay myringoplasty is an effective surgical technique for the repair of tympanic membrane perforations in terms of graft take up and improvement of hearing.

Effect of Local Estrogen on Repairing Tympanic Membrane Perforation.

Introduction:Tympanoplasty is a surgical treatment of tympanic membrane perforation. Many efforts have been made to increase the success rate of tympanoplasty. Some studies confirmed the positive role of estrogen in wound healing. The current study was conducted to evaluate the effect of topical estrogen on the success rate of tympanoplasty.Materials and Methods:A total of 85 patients were randomly assigned to the case and control groups. Otomicroscopic examination was performed before and 3 months following the operation. At the final stage of tympanoplasty, gelfoam was placed on the lateral side of the graft. It was soaked in dexamethasone in the control group and combination of dexamethasone and estradiol valerate solution in the case group. Hearing thresholds were measured by audiometric tests pre- and postoperatively. Hearing levels were assessed as the mean air conduction (AC) at 500, 1000, and 2000 Hz. The graft status was evaluated using otomicroscopic examination 3 months following the operation. Results:Otomicroscopic examination revealed successful graft healing in 23 of 37 and 29 of 36 patients in the control and case groups, respectively. A higher rate (80.55%) of graft repair was observed in the estradiol group, compared to that (62.16%) reported for the control group; however, the difference was not statistically significant (P=0.08). The average improvement values of the AC levels were 20.45 and 24.7 dB in the control and case groups, respectively (P=0.3). Statistical analysis among the subgroup of patients with small perforations showed that the success rate of tympanoplasty was significantly higher in the estradiol group, compared to that reported for the control group (P=0.03). Conclusion:Although topical estrogen was generally ineffective in increasing the success rate of tympanoplasty, it improved the success rate among patients with small tympanic membrane perforations.

Therapeutic Contact Lenses in the Treatment of Corneal and Ocular Surface Diseases-A Review.

Therapeutic contact lenses (TCLs) are often used in the management of a wide variety of corneal and ocular surface diseases (OSDs). Indications of TCL include pain relief, enhancing corneal healing, corneal sealing, corneal protection, and drug delivery. For painful corneal diseases such as bullous keratopathy, epidermolysis bullosa, and epithelial abrasions/erosions, bandage contact lenses (BCLs) provide symptomatic relief. Postoperatively in photorefractive keratectomy or laser epithelial keratomileusis, BCLs also alleviate pain. In severe OSDs such as severe dry eye, Stevens-Johnson syndrome/toxic epidermal necrolysis, gas-permeable scleral contact lenses are often used to enhance corneal healing. BCLs are used post-keratoplasty, post-trabeculectomy, and post-amniotic membrane transplantation to enhance healing. BCLs, with or without glue adhesives, are used to seal small corneal perforations and sometimes also used as bridging treatment before penetrating keratoplasty in larger corneal perforations. In patients with eyelid conditions such as trichiasis, ptosis, and tarsal scarring, BCLs are also effective in forming a mechanical barrier to protect the cornea. A relatively new use for TCLs is in ocular drug delivery where TCLs are used to maintain therapeutic concentrations of medication on the ocular surface. Contraindications of the use of TCLs include infective keratitis, corneal anesthesia, and significant exposure keratopathy with inadequate eyelid position or movement. Complications of TCL include infective keratitis, corneal hypoxia and associated complications, corneal allergies and inflammation, and poor lens fit. Overall, TCLs are effective in the treatment of corneal and OSDs but contraindications and complications must be considered.

STUDY OF DIFFERENT TYPES OF GRAFT MATERIALS USE IN TYPE - I TYMPANOPLASTY AT ENT DEPARTMENT OF SKMCH, MUZAFFARPUR, BIHAR

Background: The present study was undertaken to compare the results of various autogenous tissues as grafting materials for the repair of the tympanic membrane defect. As all the materials used previously were not easily available. So the present study comprised of the materials, which were easily available in adequate amount. These were temporalis fascia, tragalperichnodrium, areolar tissue and Ear lobule fat. Methods: In 100 subjects tympanoplasty operation was performed in 100 ears. The age of subjects ranged from 11 years to 50 years with mean age being 28.9 years. 33 cases were male and 67 cases were female. Majority (62%) of them were residing in rural areas and rest (38%)were from urban population. The period of study was from May 2019 to April 2020 starting from the pre-operative assessment to post– operative follow up all findings were noted in specific proforma. All of them attended ENT outpatient department of Sri Krishna Medical College and Hospital, Muzaffarpur, Bihar, with the chief complaints of discharging ear of varying duration. Slight impairment of hearing of varying degree was also complained of. Few of them presented with active stage of the disease and they were treated conservatively so that they attained the criteria as mentioned previously for myringoplasty operation of the present study. Results: Temporal fascia – None of the operated case reached the excellent result of post operative A-B gap closure by 0 – 10 dB. 23 cases showed good A-B gap closure of 11 – 20 dB followed by 9 cases with fair A – B gap closure of 21 – 30 dB and 5 cases showed poor result of >30 dB A-B gap closure. Tragal perichondrium –None of the operated case reached the excellent result of post operative A-B gap closure by 0 -19 dB 5 cases showed good A-B gap closure by 11 -20 dB, followed by 3 cases of fair A-Bgap closure 21 – 30 dB and 1 case of poor result with >30 dB A- B gap closure. Areolar tissue – None of the operated case reached the excellent result of post operative A-B gap closure by 0 -10 dB. 6 cases showed good A-B gap closure by 11 – 20 dB, followed by 2 cases of fair i.e. 21 – 30 dB A- B gap closure. Ear Lobule fat – 8 out of 45 cases showed excellent result with post operative A-B gap closure by 0 – 10 dB followed by 32 cases with good A-B gap closure by 11 – 20 dB, followed by 5 cases of fair i.e. 21 – 30 dB A-B gap closure. Conclusion: Tympanoplasty using Fat from ear lobule has high success rate of 90% for tiny small perforations. It is an office procedure which is cost effective with minimum post operative morbidity. But it is an underused procedure. We should practice it more for the benefit of our patients. Further long term study with more number of patients and verities of graft materials are necessary to achieve detailed and accurate results.

Intensity-modulated Radiation Therapy (IMRT) May Reduce Diarrhea With Similar Treatment Efficacy Even In Japanese Treatment Strategy For Cervical Cancers

The RTOG 1203 trial showed that IMRT after hysterectomy could reduce acute radiation enteritis (ARE) compared to 3-dimensional conformal radiotherapy (3DCRT). However, it should be investigated whether IMRT could reduce ARE in radical radiotherapy for cervical cancers, considering the inter- and intra-fractional motions of the uterus (5-15 mm) and larger target volume. In Japan, treatment strategy for cervical cancers differs from that of other countries. The intestine is shielded during whole-pelvic irradiation (WPI) and brachytherapy starts earlier. Thus, even in 3DCRT, the ARE incidence can be lower than in other countries. We applied radical IMRT for cervical cancers using tomotherapy and investigated whether the IMRT protocol could reduce ARE and other toxicities. We reviewed patients with cervical cancers treated at 3 institutions that employed the same protocol. In the protocol, patients with UICC 8th stage IB-IVA cervical cancers received radical WPI ± paraaortic irradiation with 45-50.4 Gy delivered at a daily fraction of 1.8 Gy five times a week. Platinum-containing chemotherapy was delivered to ≥ stage III or tumors with ≥ 4 cm in the maximum diameter. After 20-30 Gy of WPI depending on the stage, the rectum, bladder and intestine were shielded and intracavitary brachytherapy (2-4 times at a point A dose of 5-6 Gy) was carried out. In IMRT, a block structure was contoured instead of the center shielding in 3DCRT. The block structure median dose was reduced to ≤ 0.9 Gy/fr. From 2007 to 2011, 3DCRT was used. From 2012, the IMRT protocol was introduced. We compared the IMRT and 3DCRT groups. All patients treated with the protocols were analyzed except patients with: 1) previous history of hysterectomy or radiotherapy and 2) small cell cancer. ARE was defined as the increase in stool of 4–6 times per day over the baseline. In total, 169 patients were treated according to the protocols. Of them, IMRT was delivered to 93 (median age, 63 years) and 3DCRT to 76 (61 years). Chemotherapy was administered to 73 in the IMRT group and 50 in the 3DCRT group (p = 0.08). Lymph node metastases were seen in 44 in the IMRT group and 26 in the 3DCRT group (p = 0.12). The 3-year overall survival and locoregional recurrence rates after IMRT were 84% and 17%, respectively. In the 3DCRT group, these rates were 70% and 20%, respectively. No difference was seen between the 2 groups (p > 0.2). ARE occurred less frequently in the IMRT group than in the 3DCRT group (17/93 vs 24/76, p < 0.05). Grade 3 toxicities were observed in 5 in the IMRT group (rectal bleeding 2, sigmoid colon stenosis 1, bladder tamponade 2) and in 3 in the 3DCRT group (rectal bleeding 1, small intestinal perforation 2) (p = 0.73). There was no ≥ grade 4 toxicity in both groups. Even in the Japanese treatment strategy for cervical cancers, use of IMRT may reduce ARE with similar treatment efficacy.

Paediatric acquired cholesteatoma, our experience in a tertiary care: two year prospective study

&lt;p&gt;&lt;strong&gt;Background:&lt;/strong&gt; Aim of the study was to estimate the benefits of having high-resolution computed tomography (HRCT) of temporal bone on clinically evaluated paediatric patients of acquired cholesteatoma.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A total of 60 patients of paediatric age group (2-18 years) who were diagnosed with active squamosal type of chronic otitis media were selected for the study. HRCT of temporal bone was done in all the patients and findings were recorded.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results:&lt;/strong&gt; Most patients were in the age group of 11-15 years (46.6%). Findings of pars tensa were subtotal perforation in 2 patients (3.3%), small central perforation in 8 patients (13.3%) and postero-superior marginal perforation in 12 patients (20%). Pars flaccida retraction pocket with cholesteatoma was seen in 31 patients (51.6%) and perforation with cholesteatoma in 13 patients (21.6%). Scutum erosion was seen in 31 patients (51.6%), ossicular erosion in 12 patients (20%) and facial nerve paralysis in 2 patients (3.3%). On HRCT temporal bone we found soft tissue density in middle ear in 60 patients (100%), soft tissue density in mastoid in 53patients (88.3%), osscicular erosion in 54 patients (90%), scutum erosion in 46 patients (76.6%), facial nerve canal dehiscence in 5 patients (8.3%), semicircular canal dehiscence in 2 patients (3.3%) and dural plate dehiscence in 11 patients (18.3%).&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; HRCT of temporal bone is helpful in depicting a clearer picture of middle ear cavity structures involved by cholesteatoma and thus helpful in formulating a strategy for further management.&lt;/p&gt;

Dual fat boundary method: the fat boundary method in elasticity with an extension of the application scope

The fat boundary method (FBM) is a fictitious domain method, proposed to solve Poisson problems in a domain with small perforations. It can achieve higher accuracy around holes, which makes it very suitable to solve elasticity problems because stress concentrations often appear around holes. However, there are some strict restrictions of the FBM limiting the wide range of applications. For example, the original FBM deals with perforated rectangular domain with only Dirichlet boundary conditions. Furthermore, because the global domain is extended to the holes, analytical solutions in holes corresponding to the Dirichlet boundary conditions around holes are required. This limits both the boundary conditions around holes and the shape of holes, because for arbitrary holes it is difficult to get the analytical solutions. This article makes an attempt to break these limitations and apply the FBM to elasticity. Firstly, we review the FBM and introduce Neumann boundary conditions to the rectangular domain. A mathematical proof of the conditional convergence of the algorithm is presented. Furthermore, the FBM is compared with the Lagrange multiplier method to clarify that the FBM is one kind of weak imposition method. Then we apply the FBM to linear elasticity and the dual fat boundary method is proposed to solve problems without analytical solutions in holes. Some numerical examples are presented to verify the method proposed here.

Clinical and radiographic outcomes of reentry lateral sinus floor elevation after a complete membrane perforation.

Although small perforation of the maxillary sinus schneiderian membrane is a well-documented complication during lateral sinus floor elevation (LSFE), complete perforations larger than 10 mm often result in discontinuation of surgery. Reports on reentry LSFE and its long-term outcomes are sparse. To evaluate the long-term outcomes of reentry LSFE following complete membrane perforation to elucidate the technical details of the reentry procedure. We assessed the medical records of all patients receiving LSFE from 2008 to 2017 in the Department of Oral Implantology, Peking University Hospital of Stomatology. Twenty-two patients receiving reentry LSFE after complete membrane perforation were enrolled. Data were recorded using cone beam computer tomography: including the residual bone height, membrane thickness of the sinus prior to surgery (MT1 ), and before reentry (MT2 ), and height of the bone graft during the reentry procedure (HBG). Cumulative survival rate of implants (CSR), marginal bone loss (MBL), and subsequent complications were also recorded. From 2008 to 2017, 2023 consecutive patients (2262 sinuses) who underwent LSFE were screened. Complete membrane perforation occurred in 28 patients and resulted in discontinuation of surgery (1.2%). Twenty two patients were enrolled and received reentry LSFE within 3-6 months. Two patients undergoing the reentry procedure were suspended due to excessive membrane perforation, while the other 20 finished reentry sinus bone graft. In the reentry procedure, the HBG was 9.73 ± 2.67 mm with 34 implant placements. The MT1 and MT2 were 1.03 ± 0.43 and 1.91 ± 1.45 mm, respectively, showing a statistically significant difference (P < .05). After a follow-up of 2-10 years, CSR was 97.1%, and MBL was 0.64 ± 0.50 mm. The long-term outcome of reentry LSFE is predictable and reentry LSFE offers a reliable alternative following complete membrane perforation. However, the procedure is relatively sensitive and should be performed by experienced surgeons.