胆道闭锁婴儿亲属活体肝移植术后空肠穿孔四例

目的 分析胆道闭锁婴儿亲属活体肝移植术后空肠穿孔的原因,总结治疗经验.方法 胆道闭锁婴儿行亲属活体肝移植者28例,术后应用环孢素A、糖皮质激素预防排斥反应,部分患儿加用吗替麦考酚酯.结果28例中4例(14.3%)发生空肠穿孔,共发生7次,发生时间平均为术后11 d(8～13 d).4例的穿孔部位均在空肠,其中3例在肠吻合口丝线缝合线脚处,1例在肠袢臂固定丝线线头处.肠吻合口丝线缝合线脚处穿孔的3例经丝线缝合修补穿孔后,其中2例(67%)再次出现穿孔,用prolene线修补后愈合.无患儿因空肠穿孔而死亡.结论 胆道闭锁婴儿行亲属活体肝移植后发生空肠穿孔可能与用丝线吻合肠道有关,可换用Prolene线吻合肠道或修补穿孔.早期诊断和早期剖腹探查对空肠穿孔的治疗至关重要.

Abstract：

Objective To investigate the cause of jejunum perforation after infantile livingrelated liver transplantation (ILRLT) and summarize the experience of treatment. Methods The clinical data of 28 infants with biliary atresia who underwent ILRLT were analyzed and 4 of 28 infantile recipients (14. 3%) developed jejunum perforation after ILDLT. Results Four patients had 7 episodes of jejunum perforation after transplantation among 28 infantile recipients who underwent ILRLT because of biliary atresia. The median time between transplantation and perforation was 11 days.Perforation occurred at the point of silk in jejunum stoma (n = 3) and the Roux-en-Y limb (n = 1 ).None had a history of prior operation including Kasai in 4 patients. Clinical manifestation included fever, increased heart rate, abdominal distention, leukocytosis, and no free air on abdominal roentgenograrns. A simple repair was performed in three infants with silk: two developed recurrent perforation (67%) and underwent a re-exploration,and another had a third perforation and underwent a third repair because of re-perforation. Another child underwent a simple repair with prolene, and there was no recurrence. None died from the perforation in our study. Conclusion The occurrence and location of jejunum perforation after ILDLT suggests that the cause of the perforation is related to the jejunal anastomosis with silk, and the jejunum perforation may be avoided in the jejunal anastomosis with prolene. Early diagnosis and exploration may ensure better survival.     

腹腔镜胃十二肠溃疡穿孔修补辅助H2受体拮抗剂治疗急性胃十二指肠溃疡穿孔

目的:总结腹腔镜下胃十二指肠溃疡穿孔修补术的临床经验。方法:回顾分析采用腹腔镜行胃十二指肠溃疡穿孔修补术的33例临床资料。结果:除1例十二指肠溃疡穿孔时间较长中转手术外,29例十二指肠球部穿孔和3例胃穿孔患者腹腔镜手术均获得成功,无并发症发生;术后辅助H2受体拮抗剂治疗,胃镜复查无复发。结论:腹腔镜修补并H2受体阻断剂口服治疗胃十二指肠溃疡急性穿孔的效果是肯定的,值得临床应用推广。     

Duodenal ulcer perforation: the effect of H2 antagonists?

One hundred and two patients with perforated duodenal ulcers over a 13 year period (1970 to 1982) have been prospectively followed-up at a special gastric clinic. Of the 37 patients with perforation of their acute ulcer, 34 were treated by oversew and three had an initial definitive operation (vagotomy and drainage). The remaining 65 patients presented with perforation of a chronic ulcer and 54 were treated by oversew and 11 underwent definitive surgery--nine had vagotomy and drainage and two had partial gastrectomies. Seven of the 34 patients (20.5%) with acute ulcer perforation treated by simple oversew subsequently required definitive ulcer surgery at a mean 17.5 months after perforation and 31 of the 54 patients (57.4%) with chronic ulcer perforations required definitive surgery at a mean 27.4 months after perforation. The introduction of H2 antagonists in 1977 did not alter the re-operation rate in patients with chronic ulcer perforation managed by oversew. Results of this study provide further evidence in favour of treating patients with perforation of their chronic duodenal ulcer by definitive surgery whenever possible.     

Geographic and socioeconomic predictors of perforated appendicitis: A national Canadian cohort study

Background/PurposeAppendiceal perforation significantly impacts the outcomes of pediatric appendicitis. While socioeconomic status affects perforation risk in the United States, these effects should dissipate in a universal healthcare system. The specific spatial patterns associated with perforation have also never been delineated. This study examined the effect of geography and SES on appendiceal perforation in Canada's universal healthcare system.MethodsUsing administrative databases, Canadian children with appendicitis from 2008 to 2015 were identified. Perforation rates were examined based on rurality, distance from treating hospital, and SES. A spatial analysis identified neighborhoods with high perforation rates. Predictors of high perforation clusters were determined using logistic regression.ResultsOver the study period, 43,055 children with appendicitis were identified. The overall perforation rate was 31.5%. Rural neighborhoods and those > 125 km from the treating hospital were more likely to be within a high perforation cluster (OR 2.39, 95%CI 1.31–4. 02, p = 0.001; and OR 2.55, 95%CI 1.35–4.47, p = 0.001, respectively). Children in high perforation clusters were more likely to suffer complications. SES was not associated with perforation rates.ConclusionsIn this population-based study, appendiceal perforation was not a function of SES, but a spatial phenomenon. These findings highlight disparities in access to surgical care in Canada.Level of evidencePrognosis study, level II.     

Typhoid perforation of the intestine

We reviewed 91 cases of intestinal perforation complicating typhoid fever treated at a rural hospital in Haiti over a ten-year period. Surgical management involved simple primary closure of the perforation (80 patients), small-bowel resection with anastomosis (two patients), simple drainage of the peritoneal cavity (two patients), and serosal patching of the perforation (one patient). Six patients died before surgery. The mortality was 30.8% for all 91 cases but 21.2% for those treated with primary closure of the perforation. We also reviewed the literature pertaining to the management of intestinal perforation complicating typhoid fever.     

Radiological evidence of subcutaneous emphysema leading to a diagnosis of retroperitoneal perforated diverticulum

INTRODUCTIONThis case report outlines the investigation and management of a young patient presenting with left iliac fossa pain and sepsis. A CT was performed which was initially reported as not showing a perforation, however closer analysis provided evidence of subcutaneous emphysema in the anterior abdominal wall. This evidence justified urgent operative intervention. We review the evidence with regard to this presentation.PRESENTATION OF CASEA previously fit 24-year-old male presented with left iliac fossa pain and features of sepsis. A CT provided subtle but distinctive evidence of retroperitoneal perforation secondary to diverticulitis, in the form of surgical emphysema in the anterior abdominal wall. In view of this, urgent operation was considered justified on suspicion of visceral perforation. A diverticular perforation was confirmed intra-operatively, and a sigmoid colectomy with primary anastomosis was performed, together with a covering ileostomy. The patient made a good post-operative recovery.DISCUSSIONDiverticular disease and its complications are becoming more common in a younger age group, in whom perforation may present late or may not be suspected. In this context special attention must be paid to any radiological evidence of perforation.CONCLUSIONSurgical emphysema in the abdominal wall is an indicator of retroperitoneal perforation, and its presence should be excluded before the possibility of perforation is dismissed. This may be of especial value in younger age groups amongst whom perforation may be less clinically obvious.     

消化性溃疡穿孔非手术治疗病例报告及分析

目的探讨消化性溃疡穿孔的非手术治疗。方法回顾我院近年来消化性溃疡穿孔行非手术治疗的病例，并结合文献进行分析。结果十二指肠溃疡单纯穿孔患者非手术治疗均有效，而胃穿孔患者非手术治疗后中转手术。结论十二指肠溃疡单纯穿孔非手术治疗有可能成为一种趋势。     

应用无机三氧化物即刻修补根管穿孔的临床观察

目的：观察并评价以无机三氧化聚合物（mineral trioxide aggregate,MTA）即刻修补根管侧壁穿孔的临床效果。方法：选取根管侧壁穿孔患牙10例,采用MTA修补,完成根管充填及冠部修复。术后3、6、12个月复查,观察穿孔处根周组织变化和患者临床表现,评价修复根尖穿孔效果。结果：10例患者均在完成即刻修补后2天内观察无异常而完成后续根管或修复治疗,1例由于侧穿范围过大治疗失败,其余9例患牙无不适,术后X线片显示充填物致密,随访中X线片示穿孔处根周无暗影出现,2例有少量材料超充,但未引起临床症状。结论：MTA治疗根管穿孔患牙临床效果确切,值得临床推广应用。     

Spontaneous perforation of the small intestine as rare cause of acute abdomen

Spontaneous perforation of the small bowel as a cause of acute abdomen are seldom observed. In our patients 4 cases of non-traumatic perforation are reported. Compared with the international literature the incidence and different pathways of the perforation are discussed.     

Pathogenesis and therapy of gallbladder perforation

Findings on admission to hospital and after surgery recorded from 35 patients with gallbladder perforation were compared to findings obtained from 98 patients with cholecystitis, with a view to establishing determining factors in pathogenesis of gallbladder perforation and for the purpose of improving therapeutic strategies. That comparison was part of a retrospective analysis. Biological behaviours regarding perforation were found to be hard to assess, though "early operation" was found to reduce the risk of perforation and post-perforation lethality.     

Pseudoaneurysm of the abdominal aorta due to a needle-like osteophyte on the first lumbar vertebra

A 46-year-old woman was admitted with acute abdominal pain radiating to the back. Computed tomography examinations showed a needle-thin perforation of the aorta, opposite the origin of the superior mesenteric artery, with a pseudoaneurysm. A needle-sharp spinal osteophyte was located exactly opposite the perforation. There was no sign of infection, and the perforation seemed to have been caused by the osteophyte. This aortic perforation occurred without any major trauma, but repeated minor occupational trauma to her abdomen may have played an etiologic role. The pseudoaneurysm and adjacent aorta were exposed through a thoracolaparotomy. The aortic wall was normal, with good tensile strength; therefore, the perforation in the aortic wall was sutured with a double vascular suture, and the osteophyte was resected. To our knowledge, aortic perforation due to a vertebral osteophyte in the absence of major trauma has not previously been described.     

单向倒刺缝线在腹腔镜胃十二指肠巨大溃疡穿孔修补术的使用经验

目的探讨单向倒刺缝线在穿孔直径≧1.0 cm的胃十二指肠溃疡穿孔病例腹腔镜下修补的安全性与疗效。方法回顾性分析我院胃肠外科2014年2月~2017年6月采用单向倒刺缝线行腹腔镜胃十二指肠巨大溃疡穿孔修补术的32例病例,采用单向倒刺缝线对穿孔部位进行连续全层缝合,统计分析所有病例的手术时间、术中出血量、术后肛门排气时间、住院时间及并发症发生情况。结果 32例病例均成功完成手术,无中转开腹病例,围手术期无并发症发生。其中十二指肠球部前壁溃疡穿孔的有24例,胃窦前壁溃疡穿孔的有8例,穿孔部位直径≧1.0 cm且1.5 cm的病例有18例,≧1.5 cm且2.0 cm的有10例,≧2.0 cm的有4例。全组手术时间43.06±5.29 min,术中出血量9.25±3.47 m L,术后肛门排气时间34.31±7.85 h,住院时间7.53±1.02 d。结论在腹腔镜下将倒刺缝线应用于修补穿孔直径≧1.0 cm胃十二指肠溃疡穿孔病例是安全有效的,既有利于患者的恢复,同时也降低了腹腔镜下缝合难度。     

Air Insufflation of the Stomach Following Laparoscopic Pyloromyotomy May Not Detect Perforation

Background:

Undetected perforation during laparoscopic pyloromyotomy can be fatal. Detecting a perforation at the time of laparoscopic pyloromyotomy is difficult. The purpose of this study was to determine whether air insufflation of the stomach reliably detects perforation during laparoscopic pyloromyotomy.

Case Reports:

Between 2007 and 2008, 71 patients underwent laparoscopic pyloromyotomy and 2 patients (3.3%) had perforation. Insufflating the stomach with air did not demonstrate the perforation in either case. Both perforations were detected by careful inspection of the myotomy; a small amount of mucus was seen at the perforation site. Both patients underwent open suture repair with an omental patch and had unremarkable postoperative courses.

Conclusions:

Air insufflation of the stomach during laparoscopic pyloromyotomy does not reliably rule out perforation. As with all procedures with potential complications, a high index of suspicion and careful inspection of the entire myotomy may help detect perforation.     

Evolving options in the management of esophageal perforation

Esophageal perforation remains a devastating event that is difficult to diagnose and manage. The majority of injuries are iatrogenic and the increasing use of endoscopic procedures can be expected to lead to an even higher incidence of esophageal perforation in coming years. Accurate diagnosis and effective treatment depend on early recognition of clinical features and accurate interpretation of diagnostic imaging. Outcome is determined by the cause and location of the injury, the presence of concomitant esophageal disease, and the interval between perforation and initiation of therapy. The overall mortality associated with esophageal perforation can approach 20%, and delay in treatment of more than 24 hours after perforation can result in a doubling of mortality. Surgical primary repair, with or without reinforcement, is the most successful treatment option in the management of esophageal perforation and reduces mortality by 50% to 70% compared with other interventional therapies.     

Carcinoma of the sigmoid colon: an unusual cause of Fournier's gangrene.

We report a case of perforated adenocarcinoma of the sigmoid colon in an inguinal hernia presenting as Fournier's gangrene. Bowel perforation has been known to cause this disease but, to our knowledge, perforation in an inguinal hernia due to benign or malignant disease has not been reported elsewhere. Gastrointestinal tract perforation should be sought as a potential etiology in patients with necrotizing fasciitis of the genitalia. When such a perforation exists occult malignancy should be ruled out.     

EST严重并发症的外科治疗

目的探讨EST术后严重并发症的外科治疗。方法收治14例EST术后并发严重出血、穿孔、胰腺炎病人。其中单纯出血5例，单纯穿孔5例，穿孔伴出血3例，穿孔伴重症胰腺炎1例。结果单纯出血4例、单纯穿孔5例、穿孔伴出血2例病人存活。单纯出血1例、穿孔伴出血2例及穿孔伴重症胰腺炎1例病人死亡。结论早期诊断，积极手术是降低死亡率的关键。对穿孔伴出血或胰腺炎的病人，为减少胆汁、胰液对EST切口的刺激，应建立通畅的腹腔引流。     

Management of delayed oesophagus perforation and osteomyelitis after cervical spine surgery: review of the literature

Oesophagus perforation is a possible complication of anterior cervical spine surgery, which generally occurs during the first postoperative days. Delayed perforation is very rare and its management remains controversial. We report the successful management of a delayed oesophagus perforation associated with an osteomyelitis.     

Idiopathic Colonic Perforation in Adult—A Rare Case

Idiopathic perforation of normal colon in adults is rare. The cause for idiopathic perforation is not known. We report a case of idiopathic colonic perforation in adult who presented with sign and symptoms of perforative peritonitis. On laparotomy patient was diagnosed to have a colonic perforation. There was no causative factor for perforation in the patient. This case is reported because of rarity of this disease     

胃癌急性穿孔的外科诊断和治疗

Objective To explore the diagnosis, treatment and prognosis of acute perforation of gnstric cancer. Methods The clinical data of 24 patients with acute perforation of gastric cancer who had been admitted to Guangzhou General Hospital of PLA from July 1996 to December 2008 were retrospectively analyzed. Results Of all patients, 4 were treated by perforation repair, 2 by perforation repair combined with gastrojejunostomy, 11 by palliative subtotal gastrectomy, 2 by radical gastrectomy, and 5 by radical gastrectomy after perforation repair. The mean survival time of patients treated by perforation repair, perforation repair combined with gastro-jejunostomy, partial gastrectomy and radical gastrectomy were (4±5), (6±9), (12±7), and (25±9) months, respectively. Conclusions Early diagnosis and reasonable operation are the keys to decrease the morality and increase life quality for patients who suffered from acute perforation of gastric cancer. Different pathologic stages maybe an important factor in deciding the prognosis.     

Decision for surgical management of perforation following endoscopic sphincterotomy

Duodenal perforation resulting from endoscopic sphincterotomy (ES) is a serious complication with a high mortality. Diagnosis is often problematic and the optimum treatment is controversial. Eight proven perforations occurred following 441 ES at University of Colorado Hospital, a rate of 1.8 per cent. Physical and laboratory findings were of little diagnostic value, whereas plain abdominal radiographs showed evidence of perforation in 86 per cent. All patients were operated on promptly after diagnosis of perforation. Delay in diagnosis of perforation beyond 24 hours in six patients was associated with a high morbidity and two deaths. Analysis of published series confirmed that delay in diagnosis and delay in operation after perforation were associated with a higher mortality rate than early diagnosis with or without operation. We recommend operative intervention in all patients with clinical evidence of perforation following ES.