Successful sealing of perforation of saphenous vein graft by coronary stent.

Coronary artery perforation is a rare occurrence during angioplasty and could lead to major complications requiring emergency surgical intervention. We describe a case of perforation of a saphenous vein graft during stenting. The perforation was successfully sealed by a second coronary stent.     

Repair of left anterior descending coronary artery perforation by Magic Wallstent implantation.

Coronary rupture is a rare complication of percutaneous coronary intervention. However, it may be associated with serious hemodynamic consequences often leading to tamponade, myocardial infarction, emergency surgical intervention, or death. We report a successful percutaneous repair of a brisk left anterior descending coronary artery perforation by the implantation of a Magic Wallstent.     

A wristwatch in the esophagus associated with esophageal perforation: report of an intriguing case

Foreign bodies in the esophagus are commonly seen in emergency medicine. We report here on a very rare case of a working wristwatch in the esophagus, which was successfully extracted by surgical intervention along with primary repair of the perforated cervical esophagus through a transcervical incision. This watch was impacted for 4 days in the cervical esophagus of an adult schizophrenic patient and resulted in cervical esophageal perforation associated with acute deep neck infection.     

Health-related quality of life outcomes after cholecystectomy

Gallbladder diseases are very common in developed countries. Complicated gallstone disease represents the most frequent of biliary disorders for which surgery is regularly advocated. As regards, cholecystectomy represents a common abdominal surgical intervention; it can be performed as either an elective intervention or emergency surgery, in the case of gangrene, perforation, peritonitis or sepsis. Nowadays, the laparoscopic approach is preferred over open laparotomy. Globally, numerous cholecystectomies ar...     

冠状动脉介入治疗并发冠状动脉穿孔的处理

目的 :探讨冠状动脉穿孔的正确处理方法。方法 :连续 14 70例患者接受介入治疗过程中有 7例并发冠状动脉穿孔 ,根据不同类型 ,分别采用密切观察、支架覆盖、弹簧圈堵塞等方法。结果 :所有患者均未接受外科手术 ,预后良好 ,康复出院。结论 :冠状动脉穿孔系冠心病介入治疗急性严重并发症 ,处理适当预后良好 ,处理不当将致严重后果 ,甚至死亡。处理时并非都需外科手术治疗     

Paraesophageal hiatus hernia in the aged.

A review of the records of Granada Hills Hospital revealed 4 documented cases of paraesophageal hiatus hernia. One of these geriatric patients presented with incarceration of the gastric fundus, and required an emergency thoracotomy for relief. Paraesophageal hiatus hernia, unlike sliding hiatal hernia, often gives rise to acute surgical problems secondary to incarceration, obstruction, gangrene, perforation or hemorrhage. The approach to the repair operation, may be either abdominal or thoracic, dependent upon the need to correct other associated gastrointestinal pathologic lesions. Unless severe debilitating medical diseases are present, operative intervention is recommended.     

Utility of fever and leukocytosis in acute surgical abdomens in octogenarians and beyond

BACKGROUND: The study determined the incidence of specific surgical diagnoses in patients age 80 years or older who presented to an emergency department (ED) with acute abdomens and required emergency surgical intervention within 72 hours. The usefulness of an increase in temperature and leukocytosis in the evaluation of each surgical diagnostic group is discussed. METHODS: The study was a retrospective review of ED records and operative reports of patients 80 years or older who were seen from November 1992 to September 1995 at a large midwestern tertiary-care ED with 65,000 annual patient visits. RESULTS: Among the 117 patients who met the inclusion criteria, the most common diagnoses were acute cholecystitis (29 patients), hernia (24), and bowel obstruction (19). The least common diagnoses were Meckel's diverticulum (1 patient), diverticulitis (1), and a carcinoid tumor (1). Temperature increase to more than 37.5 degrees C was statistically more common in patients with acute cholecystitis (13 of 29) and viscus perforation (4 of 11) than in all other patient groups (4 of 77). A leukocyte count of more than 15,500/mm3 was most statistically suggestive of acute cholecystitis (10 of 29 patients), intestinal ischemia (5 of 11), viscus perforation (5 of 11), acute appendicitis (2 of 3), and abscess (1 of 2). Of 115 patients with a recorded temperature and leukocyte count, 35 had a temperature of less than 37.5 degrees C and a leukocyte count of less than 10,500/mm3. CONCLUSION: Acute surgical abdomen in patients 80 years or older has a unique distribution of diagnoses. Although an increase in temperature and marked leukocytosis are not diagnostic of any particular illness, their presence should suggest certain specific surgical illnesses to the practicing clinician. Frequently, elderly patients with acute surgical abdomens present with a normal temperature and leukocyte count.     

Abdominal surgical emergency in the elderly.

BACKGROUND/AIMS: Longer life expectancy has created an increasing demand for surgical care of the elderly. Abdominal surgical emergencies are potentially serious and life-threatening conditions for this group of patients. The aim of this study was to evaluate the records of elderly patients undergoing emergency surgical treatment. METHODS: A total of 181 patients aged 60 years and above who had undergone emergency surgical interventions were retrospectively analysed according to demographic features, indications for emergency surgery, postoperative clinical course and outcome. RESULTS: Sixty-one percent of the patients were male, with an average age of 70.3 (range 60-95) years. Octogenarians constituted 19% of our series. Causes of surgical emergency were acute cholecystitis (31.5%), strangulated hernia (18.2%), hollow viscus perforation (17.1%), bowel obstruction (10.5%), acute mesenteric ischaemia (9.4%), acute appendicitis (8.3%) and upper gastrointestinal haemorrhage (5%). Gallstones had been previously detected by ultrasound in 25 (45.5%) of 55 patients with acute calculous cholecystitis. Thirty (93.8%) of 32 patients were aware of their external hernias prior to incarceration. Twenty seven patients (14.4%) died in the early postoperative period, with acute mesenteric vascular occlusion being the leading cause of death: A higher mortality rate was noted in mesenteric ischaemia (76.5%), gastrointestinal bleeding (22.2%) and in perforation (19.4%) cases, being 36.8% (21/57) in patients with these three severe conditions and 4.8% (6/124) in the remaining patients. CONCLUSIONS: Acute calculous cholecystitis and external strangulated hernias, which are generally preventable, were the most common surgical emergencies. Surgical treatment of acute mesenteric ischaemia, gastrointestinal haemorrhage and peritonitis secondary to free perforation had a worse prognosis in older patients.     

Coronary perforation during percutaneous coronary intervention

Coronary perforation is an undesirable complication during percutaneous coronary intervention (PCI). We reviewed the cases of overt coronary perforation in our institute and analyzed their clinical backgrounds, the characteristics of the target lesion, management, and clinical outcomes. Between 1991 and 2005, we experienced 12 cases (0.35%) of coronary perforation in a total of 3415 PCI procedures. The perforation occurred during the use of debulking devices in 3 cases, immediately after stenting in 2, immediately after postdilatation of the stent in 2, and during wiring in 3 cases. Restoration was attempted by long inflation of a balloon in 7 cases, implantation of a covered stent graft in 1, and emergency surgical repair in 1 case. Subsequent cardiac tamponade occurred in 3 patients who required pericardiocentesis, and 1 patient died due to congestive heart failure. Administration of protamine was effective in stopping the bleeding in 6 patients, whereas continuation of antiplatelet therapy resulted in no overt rebleeding. Coronary perforation during PCI is a rare complication but is associated with significant morbidity and mortality. Intravenous administration of protamine is effective when it is used in conjunction with nonsurgical devices for initial management of perforation.     

Conservative management of contained coronary perforation after percutaneous intervention.

Contained perforation of the coronary artery may occur following coronary intervention and is generally managed aggressively with acute percutaneous or surgical intervention. We report a case of contained perforation following intervention on an occluded right coronary artery, leading to lumenal compression by perivascular hematoma and reduced distal flow. This was managed conservatively with an excellent clinical and angiographic outcome.     

Beta 2-microglobulin amyloidosis presenting as intestinal perforation in a haemodialysis patient

Long term haemodialysis patient is subject to several complications such as generalised amyloidosis which is the result of deposits of beta2-microglobulin not depurated by haemodialysis. Digestive location causes ischemic accidents such as ulcer, infarctus, digestive haemorrhage, pseudo-obstruction and perforation manifested by a surgical emergency. Our observation is the 6th case of intestinal perforation caused by amyloidosis deposit reported in the literature.     

Palliative cardia resection with gastroesophageal reconstruction for perforated carcinoma of the gastroesophageal junction

Iatrogenic perforation of esophageal cancer or cancer of the gastroesophageal （GE） junction is a serious complication that, in addition to short term morbidity and mortality, significantly compromises the success of any subsequent oncological therapy. Here, we present an 82-year-old man with iatrogenic perforation of ad- enocarcinoma of the GE junction. Immediate surgical intervention included palliative resection and GE reconstruction. In the case of iatrogenic tumor perforation, the primary goal should be adequate palliative （and not oncological） therapy. The different approaches for iatrogenic perforation, i.e. surgical versus endoscopic therapy are discussed.     

Delayed perforation after endoscopic submucosal dissection for early gastric cancer: Clinical features and treatment

Perforation is an important procedural complication of endoscopic submucosal dissection (ESD) for early gastric cancer. Although the incidence of delayed perforation after ESD is low, extreme caution is necessary because many cases require surgical intervention. Among 1984 lesions of early gastric cancer treated in our hospital by ESD in 1588 patients from September 2002 through March 2015, delayed perforation developed in 4 patients (4 lesions, 0.25%). A diagnosis of delayed perforation requires prompt action, including surgical intervention when required.     

Diagnosis and treatment of gallbladder perforation

INTRODUCTION Gallbladder perforation (GBP) is a rare but life threatening complication of acute cholecystitis. Sometimes GBP may not be different from uncomplicated acute cholecystitis with high morbidity and mortality rates because of delay in diagnosis[…     

Left ventricular perforation following percutaneous mitral valvuloplasty. Its emergency surgical correction in situ. Apropos a case

Percutaneous mitral valvuloplasty is actually accepted as alternative to surgery for treatment of rheumatic mitral stenosis, although today it is not still free from troublesome complications like ventricular perforation. We present here a patient in which was performed a percutaneous mitral valvuloplasty and that developed a left ventricular perforation at the end of the procedure, with hyperacute cardiac tamponade, requiring an in situ surgical salvagement on an emergency basis, performing a successful repair of the ventricular rupture in the own catheterization laboratory.     

Management of iatrogenic perforation

Iatrogenic perforation of the gastrointestinal tract is a medical emergency and is inevitable. An endoscopist must maintain a high index of suspicion despite minimal or atypical symptoms and negative radiologic studies, because perforation is a complication with tremendous morbidity and mortality. The endoscopist must know how to manage this complication appropriately and to seek immediate surgical consultation. There is ongoing controversy about when a patient should undergo nonoperative or surgical therapy. An evidence-based approach to manage iatrogenic perforation is not possible. The trend in the modern era is to less invasive, nonoperative therapy, given advancements in ICU care and antibiotics. Laparoscopy or laparoscopic-assisted (minilaparotomy) surgery is also being increasingly used with outcomes comparable with conventional laparotomy. Experience and advancements in accessories have enabled endoscopic repair of iatrogenic perforation in many situations [84]. The management algorithms provided synthesize the pertinent literature into reasonable guidelines to follow. Ultimately, an individualized approach must be taken to manage the patient with an iatrogenic perforation.     

Coronary perforation during percutaneous coronary intervention in the era of abciximab platelet glycoprotein IIb/IIIa blockade: an algorithm for percutaneous management.

Coronary perforation is an uncommon but potentially life-threatening complication of percutaneous coronary intervention. The use of both atheroablative technologies for coronary intervention and adjunctive platelet glycoprotein blockade pharmacology may increase the incidence of or risk for life-threatening bleeding complications following the occurrence of coronary artery perforation. The interventional database for 6,214 percutaneous coronary interventions performed between January 1995 and June 1999 was analyzed. Hospital charts and cine angiograms for all patients identified in the database as having had coronary perforation were reviewed. Coronary perforation complicated 0.58% of all procedures and was more commonly observed in patients with a history of congestive heart failure and following use of atheroablative interventional technologies (2.8%). There was no association of abciximab therapy with either the incidence of or classification for coronary perforation. Adverse clinical outcomes (death, emergency surgical exploration) were related to the angiographic classification of perforation and were more frequently observed in patients who experienced a class 3 coronary perforation. These data suggest that specific clinical and procedural demographic factors are associated with the occurrence and severity of angiographic coronary perforation. An angiographic perforation class-specific algorithm for treatment of coronary perforation is proposed.     

Management and outcomes of coronary artery perforation during percutaneous coronary intervention

Coronary perforation is a particularly feared complication of percutaneous coronary intervention. The optimal management and predictors of adverse outcomes for these patients remain to be defined. Advances in management such as the use of polytetrafluoroethylene-covered stents have not been critically examined in terms of efficacy. We analyzed a cohort of patients who sustained coronary perforation during percutaneous coronary intervention at our institution during a 9-year period to examine the trends in incidence, management, and outcomes. The patient medical records were reviewed, and detailed angiographic analysis was undertaken to identify the predictors of adverse outcomes, including the development of tamponade, the requirement for emergency coronary artery bypass grafting, and in-hospital death. One year of follow-up was attempted for all patients. Seventy-two cases of coronary perforation were identified, with an overall incidence of 0.19%. The perforation grade and presence of chronic renal insufficiency were the only predictors of mortality on multivariate regression analysis. The use of polytetrafluoroethylene-covered stents to manage perforations was not associated with any reduction in adverse outcomes, such as the development of tamponade, the need for emergency coronary artery bypass grafting, or in-hospital death. In conclusion, coronary perforation remains a feared complication in the contemporary interventional era with significant in-hospital mortality. Emphasis should be placed on preventing this complication whenever possible, including exercising particular caution in patients with chronic renal insufficiency. The treatment of such patients should be tailored to the severity of the perforation. The optimal treatment of these patients needs to be defined, and the efficacy of covered stents needs to be studied prospectively.     

Emergency Placement of Platinum Coils to Prevent Cardiac Tamponade After Wire Perforation of an Occluded Venous Coronary Bypass Graft

A case is reported of a patient with impending cardiac tamponade due to vessel perforation following balloon angioplasty of an occluded venous bypass graft. Prolonged balloon inflation failed to seal the perforation. Leakage was controlled immediately by the delivery of two platinum coils into the perforation. In case of a vessel perforation during an attempt to recanalize an occluded coronary artery bypass, placement of intracoronary platinum coils to seal the perforation may prevent the development of cardiac tamponade.     

The therapeutic strategies in performing emergency surgery for gastroduodenal ulcer perforation in 130 patients over 70 years of age

BACKGROUND/AIMS: Gastroduodenal ulcer is a very common illness in Japan. As the number of elderly persons in Japan increases the same as in Europe and America, the number of such patients requiring a gastroduodenal emergency operation has also increased. Regarding the complications of peptic ulcer, a perforation remains the most important fatal complication. The aim of this study is to investigate the operative risk factors and the long-term recurrence rates and to define the optimal surgical procedures in emergency situations in elderly patients. METHODOLOGY: From April 1988 through March 1997, 130 patients over 70 years of age with a perforated gastroduodenal ulcer (a duodenal ulcer perforation in 50 patients and a gastric ulcer perforation in 80 patients) were operated on in an emergency situation in our clinic. We investigated the following items; medical illness, preoperative risk factor, optimal surgical procedure, postoperative organ failure and the cumulative recurrence-free rates after surgical treatment. RESULTS: A significant correlation with mortality was observed in patients with established comorbidity in the following organs: lung (P = 0.03), heart (P = 0.02), kidney (P = 0.04), and diabetes (P = 0.03). The highest postoperative mortality rate was recorded in patients who underwent a simple closure of a duodenal ulcer perforation (4 patients; 26.7%), while the lowest postoperative mortality rate was recorded in patients who underwent a simple closure and vagotomy of a duodenal ulcer perforation (3 patients; 12.5%). In gastric ulcers, the mortality rate in patients with a gastrectomy was significantly higher than in patients with a simple closure. The practical application of the three risk factors (preoperative shock, delay to surgery over 24 hours, and medical illness) was shown by the progressive rise in the mortality rate with the increasing number of risk factors. Based on the 5 postoperative years after treating a perforated duodenal ulcer, the cumulative recurrence rate after a simple closure (63.6%) was significantly higher than that after a simple closure and vagotomy (38.1%) (n = 0.02) or after gastrectomy (0%) (P < 0.001). At 5 years postoperatively, the cumulative recurrence rate after a simple closure (41.2%) was significantly higher than that after a gastrectomy (15.9%) (P < 0.01). CONCLUSIONS: In conclusion, in an emergency situation, elderly patients are in a highly unfavorable prognostic condition due to their advanced age, and comorbidity, which thus leads to poorer results, not only worldwide, but also in Japan. Based on our findings, in duodenal ulcer cases, a simple closure and vagotomy is recommended because of its low mortality and minimal stress, except for cases with a giant perforation measuring over 20 mm in diameter at the perforation hole or with severe duodenal stenosis. In stomach ulcer cases, a gastrectomy may be recommended because of its low recurrence rate.