A bacteriological study of perforated duodenal ulcers

Peritoneal fluid sampling and bacteriological examination were performed in 63 patients with perforated duodenal ulcers, and the results compared with those in 175 patients with other perforations. Bacterial culture was positive in 100 per cent of the patients whose perforations occurred in the colon, whereas it was positive in only 44.4 per cent of those with duodenal perforations, being negative in many cases when the interval from perforation to surgery was short. A mixed contamination with both aerobes and anaerobes was usually found in the cases of lower digestive tract perforation, and the isolates from duodenal perforations were uniquely aerobes in most cases. It is suggested that bacteria play a minor role in the pathogenesis of early stage duodenal perforation, which supports the technique of primary closure without indwelling drainage tubes during early stage operations following sufficient peritoneal lavage. Moreover, if the stomach is empty at the time of perforation and the peritonitis is localized, even conservative therapy seems possible, provided it is begun shortly after the perforation.     

A case and review of bowel perforation secondary to metastatic lung cancer

Gastrointestinal tract perforation (GITP) secondary to metastatic lung cancer is extremely rare. We present a case of small bowel perforation secondary to metastatic lung cancer. The objective of this study was to review the current literature and further characterize the incidence, histology, and risk of GITP secondary to lung cancer metastasis. A Medline search was done to identify all the cases of GITP attributed to metastatic lung cancer reported in the literature. Data was collected and analyzed from a collection of cases in the medical literature since 1960. We identified 98 cases of perforated lung cancer metastasis to the small intestine. Four gastric perforations, three colonic perforations, and one appendiceal perforation were also identified but not analyzed. The mean age was 64.5 years. There was a male predominance of 89 per cent versus 11 per cent female. Perforations occurred most often in the jejunum (53%) followed by ileum (28%). Combined jejunum-ileum lesions accounted for 4 per cent of perforations. No duodenal perforations were reported, though a specific site was not determined in 13 per cent of cases. Small bowel perforations were most often caused by adenocarcinoma (23.7%), squamous cell carcinoma (22.7%), large cell carcinoma (20.6%), and small cell carcinoma (19.6%). The prevalence of small bowel perforation secondary to a given primary lung cancer histology varied by region. The mean survival was 66 days with 50 per cent of patients not surviving past 30 days. Despite a high incidence of lung cancer, small bowel perforation secondary to lung cancer metastasis remains relatively rare. Perforated metastases occur more often in men and are found more commonly in the jejunum. Small bowel perforations are caused most often by adenocarcinoma; however, squamous cell and large cell carcinoma metastases are more likely to result in perforation. Small bowel perforation in this setting has a significant impact on mortality, decreasing 1-year survival to less than 3 per cent.     

Acute appendicitis. A 5-year review

A startling 31 per cent rate of perforated appendicitis in 1984 prompted a 5-year review at the Guthrie Medical Center. An increase over previous rates of 13 per cent and 0 per cent in 1964 and 1944 was confirmed in this study. Perforation accompanied 44 of 240 cases of appendicitis (18.3%); diagnostic accuracy in 295 cases undergoing operation was 81.4 per cent. Groups at risk for perforation were patients in the first decade of life (34.3% with perforations) and those over 50 years of age (48% perforated). Perforation rates were generally inversely related to accuracy. Accuracy was poorest in women in the second to fourth decade or those in the mid-portion of the menstrual cycle. When the appendix was not perforated, complications occurred in 8.7 per cent of patients while 29.5 per cent with a perforation had a complication. The mean hospital stay was prolonged by 2.5 days if the appendix was perforated. An increased awareness of the risk by both the public and physicians is essential to reduce the number of perforations.     

Colonoscopic perforations: incidence, management, and outcomes

Fiberoptic colonoscopy provides superior diagnostic and therapeutic capabilities in the treatment of lower gastrointestinal disease processes. A well-recognized, but uncommon, complication during the procedure is perforation. The purpose of this study was to determine the incidence of colonoscopic perforation, define risk factors, assess the management of these complications, and evaluate outcomes. From January 1997 through December 2003, 43,609 colonoscopies were performed in our medical center. There were 14 (0.032%) perforations (1 in 3115 procedures); 7 from diagnostic and 7 from therapeutic procedures. General surgeons performed 1243 procedures (2.9%), and their rate of perforation was 0.080 per cent compared with 0.031 per cent for gastroenterologists during the same period. Half of the perforations occurred in the rectosigmoid, and the most common mechanism was mechanical (n = 6). Perforation was identified immediately during endoscopy in 50 per cent of the patients. Thirteen of 14 perforations were treated within 24 hours; 1 was delayed 48 hours. Initial surgical management was undertaken in 11/14 patients. Initial nonoperative treatment was attempted in three and was successful in only one patient. The mean length of stay following perforation was 11.2 days (range, 4-36 days). Three patients (21.4%) had 7 postoperative complications. Colonoscopic perforations are uncommon but can be recognized early and managed surgically with acceptable morbidity and postoperative length of stay.     

Pneumoperitoneum in the newborn infant

Fifty-three newborns with pneumoperitoneum were treated between July 1980 and July 1985. The birth weights of these infants ranged from 600 to 4350 grams; nearly 75 per cent weighed less than 1500 grams. The etiology of the pneumoperitoneum and the hospital survival were reviewed. All operative patients had exploratory surgery through an upper abdominal transverse incision extending across both rectus muscles. All gastric and duodenal perforations were closed primarily; the perforations in the remaining gastrointestinal tract were generally exteriorized through the lateral edge of the wound. The single leading cause of pneumoperitoneum in the newborn is necrotizing enterocolitis, accounting for 60 per cent of the patients in this series; 78 per cent of these infants survived. All infants with ("spontaneous") ileal perforations survived. The two patients with colon perforations (from meconium plug obstruction) died, one of congenital heart disease associated with Down's syndrome and the other of hyaline membrane disease. One patient who had mild hyaline membrane disease, who was not ventilated, and who did not have mediastinal emphysema also had pneumoperitoneum for which no cause was found at laparotomy ("spontaneous"). He survived. In six critically ill infants (11% of the series) pneumoperitoneum developed secondary to mediastinal dissection of air from ventilators. None of these infants was operated on because an intestinal perforation as a source of the pneumoperitoneum could reliably be excluded by the presence of pneumomediastinum and/or a negative paracentesis. This group of infants warrants special attention, because in them "negative" laparotomies performed in search of an intestinal perforation would certainly compromise their already precarious conditions.     

Acute colonic perforation associated with colorectal cancer

Our purpose was to evaluate long-term outcome in patients presenting with acute colonic perforation in the setting of colorectal cancer. We conducted a retrospective review of 48 consecutive patients presenting with acute colonic perforation associated with colorectal cancer at a single institution. Patients presented either with free air or acute peritonitis. No patients with colonic obstruction were included. Forty-eight patients presented with colon perforation. Thirty-six had perforation at the tumor, 11 proximal to the tumor, and one distal to the primary tumor. Patients who perforated proximal to the tumor were older (74.5 +/- 2 vs 64.7 +/- 3; P < 0.04) and had a longer length of stay (46.8 +/- 17 vs 11.6 +/- 1 P < 0.001). Fourteen patients had stage II disease, 19 stage III, and 15 stage IV. Thirty-day mortality was 14 per cent (n = 7) with nine in-hospital deaths. Of 30-day survivors 29 (60%) had curative resection (21 with local perforation and nine with proximal perforation). Of these 14 received adjuvant chemotherapy. Eleven patients (33%) had either unresectable or metastatic disease on exploration. Mean follow-up was 21.5 months. Ten patients developed metastatic disease after potentially curative resections. Of these nine patients had perforations of the primary tumor. Three patients developed local recurrence and all had local tumor perforations. One-year survival was 55 per cent (n = 16). Five-year disease-free survival was 14 per cent (n = 4). There were no long-term survivors after perforation proximal to the tumor, although disease stage was comparable in both groups. We conclude that perforation proximal to a cancer is associated with a higher perioperative mortality and worse long-term outcome when compared with acute perforations at the site of the tumor. Long-term survival requires both aggressive management of the concomitant sepsis and definitive oncologic surgery.     

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.     

Chloramine T solution for intraoperative peritoneal lavage. A statistical analysis

An analysis and statistical evaluation of 1,157 cases of wound healing produced evidence to the effect that the rate of wound healing disorders could be substantially reduced by prophylactic peritoneal lavage, using 0.1 per cent chloramine-T solution. That reduction was from nine to 2.6 per cent in the author's cases. - In the context of perforations (n = 186), therapeutic peritoneal lavage, using chloramine-T, proved clearly superior to washing with physiological salt solution in coping with wound healing disorders. Here, the rate of such disorders was reduced from 22.4 to 8.3 per cent, and it dropped further to 4.5 per cent in those cases of perforation in which additional lavage was applied to the surgical wound proper.     

Endoscopic follow-up of the perforated duodenal ulcer

Since the introduction of cimetidine, multiple studies have documented that H2 antagonists will heal over 95 per cent of duodenal ulcers with 6 to 8 weeks of therapy. Despite this overall decline, it has been shown that the rate of complications from duodenal ulcers, specifically perforation, has remained virtually unchanged. A retrospective look at the perforated duodenal ulcers admitted to the Medical College of Georgia between 1978 and 1984 revealed a total of 45 patients with 39 survivors. Eighty per cent of the 39 underwent follow-up endoscopy in a period of 4 to 12 weeks after perforation. Twenty-six of these patients had been treated with omental patch and an average of 7.5 weeks of cimetidine. Sixty-five per cent of those treated with omental patch and cimetidine continued to have active ulcer disease on endoscopic follow-up. Twenty-three per cent were asymptomatic despite active disease. Perforation appears to represent the severest form in the spectrum of duodenal ulcer disease. H2 antagonists have been shown to heal over 90 per cent of duodenal ulcers with 8 weeks of therapy. This study reveals them to be less effective with the perforated ulcer. It is recommended that patients treated with omental patch and cimetidine be followed closely with endoscopy and be considered for longer medical therapy.     

Surgical management of endoscopic retrograde cholangiopancreatography-related perforations

Background: A retrospective review was carried out of consecutive cases of endoscopic retrograde cholangiopancreatography (ERCP)‐related perforation to identify risk factors and technique affecting surgical outcome. Methods: Eighteen patients (0.45%) out of 4030 ERCP performed were operated on for ERCP‐related perforation at Singapore General Hospital. Results: The group's median age was 72.5 years and 14 patients had ductal stone disease. Five perforations were discovered at ERCP while 10 required computed tomography for diagnosis. Eight patients were operated on within 24 h whereas 10 patients had surgery after 24 h. Five of six with type I (lateral duodenal) perforations had early surgery versus one of seven with type II (peri‐Vaterian; P = 0.03). There were four type III (bile duct) perforations and one type IV (retroperitoneal air). Five of six patients with type I perforation had simple repair compared with five of seven type II requiring the complex duodenal diversion procedure (P = 0.10). Three patients (16.7%) succumbed after surgery due to sepsis and myocardial infarction. Advanced age>70 years resulted in higher mortality of 30% versus none in patients <70 years (P = 0.22). Conclusions: Early diagnosis is important but difficult especially for the type II perforations. Duodenal diversion is used more frequently in patients with type II perforations and those operated on late. Advanced age contributes to poorer outcome in surgical treatment of ERCP perforations.     

Surgery for the complications of peptic ulceration in urban black patients

We report on a series of 63 urban black patients who required surgical treatment for duodenal or gastric ulcers. Intractable pain from duodenal ulceration was an uncommon indication for surgery, which was mostly required for the complications of perforation, haemorrhage and stenosis. Perforation was the most common indication for surgery in these patients, while in rural black patients pyloric stenosis is reported to be a common complication. It appears that the complications of duodenal ulcers in the urban black population now resemble those occurring in white patients. Giant duodenal ulcers were present in almost 25% of these patients and those presenting with haemorrhage required aggressive surgery to control the bleeding. Twenty-five per cent of cases of gastric ulceration proved to be malignant. These were mostly prepyloric ulcers, suggesting the need for vigorous investigation of such ulcers to exclude gastric carcinoma and early surgery if a conservative regimen fails to heal them. There was a 100% mortality rate among patients with perforated benign gastric ulcers, largely the result of late presentation.     

Non septic, surgical complications and their treatment of acute necrotizing pancreatitis in 131 cases

The authors analyse non septic, surgical complications and their treatment in 131 patients with acute necrotizing pancreatitis. Bleeding occurred in 13 patients 16 times. There were 3 cases with large intestine perforation, small intestine perforation twice in one patient and hydrothorax in 12 patients. The patients APACHE-II score was in the range of 15, 5, which was quite high. They experienced complications such as bleeding and bowel perforations mostly in those who underwent several reoperations. For the bleeding from acute duodenal ulcer conservative and surgical therapy (suturing) was executed. In the cases of intraabdominal bleeding they used several options such as, ligature, collagen mesh, Surgicell net and tamponation. Large intestine perforations were surgically treated with Hartmann's procedure or loop colostomy. The small intestine perforation was simply sutured. From the 12 patients with hydrothorax 8 underwent thoracic drainage. We lost 7 patients with bleeding, 3 with bowel perforations and 2 with hydrothorax. The authors believe that complications during therapy of acute necrotizing pancreatitis are high risk factor, but their treatment is not hopeless.     

Surgery may be curative for patients with a localized perforation of rectal carcinoma

BACKGROUND: Perforation at the time of operation adversely affects the prognosis of rectal cancer. These procedures have been termed 'palliative' or 'non-curative'. The long-term outcome of generalized perforations may be different from that of localized or contained perforations. Although the oncological results may be compromised when the tumour is perforated, results in cases where the perforation is contained may not be as bad as previously thought. An attempt was made to examine the intermediate and long-term results for locally contained perforated rectal cancers. METHODS: Some 848 patients with rectal cancer were operated on between March 1989 and December 1995. Of these, 42 (5 per cent) had a locally contained perforation of the rectum. Median follow-up was 23 (range 12-74) months. RESULTS: The survival of patients with locally contained tumour perforation who underwent resection without macroscopic residual disease (40 per cent at 5 years) was significantly better than that of patients with metastatic disease at the time of surgery (zero at 4 years) (P < 0.01). The survival of patients in whom the tumour was inadvertently perforated during operation was similar to that of patients with locally contained spontaneous tumour perforations. The incidence of local recurrence in these perforated cases was low provided that a wide tumour clearance was achievable at the time of operation. Operative mortality and morbidity rates were not significantly different but the incidence of postoperative wound infection was marginally higher among patients with perforation. CONCLUSION: If clear margins can be obtained at the time of operation the prognosis of locally contained perforated rectal cancers is good and approaches that of a potentially curative resection.     

Typhoid enteric perforations

Forty-five cases of typhoid enteric perforation are presented. The disease was most common in young males. Half of the perforations occurred during the second week of fever. Diagnosis was mainly clinical, supplemented by radiological evidence of pneumoperitoneum and confirmed at laparotomy by the presence of perforations in the terminal ileum. Laboratory investigations including Widal perforations in the terminal ileum. Laboratory investigations including Widal test and blood culture were of little value. All the 45 were managed operatively by simple closure of the perforation(s) and drainage of the peritoneal cavity. Burst abdomen occurred in 9 per cent and fecal fistula in 20 per cent. Overall mortality was 11 per cent--much lower than that reported in the literature in case of management of typhoid enteric perforations.     

Typhoid enteric perforations

Forty-five cases of typhoid enteric perforation are presented. The disease was most common in young males. Half of the perforations occurred during the second week of fever. Diagnosis was mainly clinical, supplemented by radiological evidence of pneumoperitoneum and confirmed at laparotomy by the presence of perforations in the terminal ileum. Laboratory investigations including Widal test and blood culture were of little value. All the 45 were managed operatively by simple closure of the perforation(s) and drainage of the peritoneal cavity. Burst abdomen occurred in 9 per cent and fecal fistula in 20 per cent. Overall mortality was 11 per cent—much lower than that reported in the literature in case of management of typhoid enteric perforations.     

Generalized peritonitis in India—The tropical spectrum

Generalized peritonitis is a common surgical emergency in India, the ‘Tropical Spectrum’ of generalized peritonitis being different from the western spectrum. A total 155 cases of generalized peritonitis were surgically treated at the All India Institute of Medical Sciences between 1981 and 1987, all patients undergoing peritoneal toilet with drainage after the cause of their peritonitis had been treated. The most common cause of peritonitis was peptic ulcer perforation, with simple closure being associated with a 2 per cent mortality, while typhoid perforation was the second most common cause. The diagnosis was clinical supported by the operative findings of a terminal ileal perforation while bacteriological, serological and histopathological confirmation was retrospective. Appendicular perforations were less common than in the west but the clinical picture was the same. Tubercular perforations were not uncommon with a previous history of subacute intestinal obstruction and evidence of tuberculosis on chest X-ray suggesting the diagnosis. Ruptured amebic liver abscess was the most common hepatobiliary cause of generalized peritonitis with drainage of the abscess producing good results. The average hospital stay was 15 days with an overall mortality of 8 per cent.     

What has happened to perforated peptic ulcer?

The number of elective operations for chronic peptic ulceration has decreased substantially with the widespread use of H2-receptor antagonists. We have reviewed all cases of perforated peptic ulcer in Oxford over the last 18 years (1965-82) to see if a similar change in the incidence of this major complication of peptic ulceration has occurred. Since 1976 there has been a fall in the incidence of perforated peptic ulcer from 8.7 to 6.9 cases per 100 000 population per year. The male to female ratio decreased over the review period from 4.9:1 to 1.9:1 owing to a reduced incidence of perforation in men and an increased incidence in women. The mean age of men with perforated duodenal ulcer increased from 52.3 years in 1965-70 to 59.0 years in 1977-82. One hundred and sixty-six patients treated between 1977 and 1982 have been reviewed in detail. The overall mortality in this 6 year period was 12.7 per cent with an operative mortality rate of 8.9 per cent. The majority of perforations (65 per cent) are now of acute ulcers and therefore are unlikely to be prevented by improved therapy for chronic peptic ulceration.     

Generalized peritonitis in India--the tropical spectrum

Generalized peritonitis is a common surgical emergency in India, the 'Tropical Spectrum' of generalized peritonitis being different from the western spectrum. A total 155 cases of generalized peritonitis were surgically treated at the All India Institute of Medical Sciences between 1981 and 1987, all patients undergoing peritoneal toilet with drainage after the cause of their peritonitis had been treated. The most common cause of peritonitis was peptic ulcer perforation, with simple closure being associated with a 2 per cent mortality, while typhoid perforation was the second most common cause. The diagnosis was clinical, supported by the operative findings of a terminal ileal perforation while bacteriological, serological and histopathological confirmation was retrospective. Appendicular perforations were less common than in the west but the clinical picture was the same. Tubercular perforations were not uncommon with a previous history of subacute intestinal obstruction and evidence of tuberculosis on chest X-ray suggesting the diagnosis. Ruptured amebic liver abscess was the most common hepatobiliary cause of generalized peritonitis with drainage of the abscess producing good results. The average hospital stay was 15 days with an overall mortality of 8 per cent.     

Value of retesting subjects with a positive Hemoccult in screening for colorectal cancer

Within a prospective randomized screening study for early detection of colorectal cancer with rehydrated Hemoccult II test, the possibility of increasing the specificity of the test by retesting patients with an initially positive Hemoccult II test was investigated. Of those offered the test 3561 (62.6 per cent) returned it and it was positive in 210 cases (5.9 per cent). The repeat test was performed by 184 patients and was positive in 68 (1.9 per cent). All those with a positive initial test had rectosigmoidoscopy to 60 cm and a double contrast enema. A carcinoma was found in one in seven patients with a positive retest but in only one in 100 patients with a negative retest (P less than 0.001). The specificity of the test was, therefore, increased from 95 per cent to 98 per cent and the sensitivity was unchanged. Rescreening was offered at a later date and increased numbers were available: 7147 patients returned the test and 369 (5.2 per cent) were positive. The test was repeated in 360 patients and 118 (1.7 per cent) were positive. A colorectal neoplasm was found in one in three of those with a positive repeat test, compared with one in seven of those with a negative repeat test. In conclusion, screening for early detection of colorectal cancer with a rehydrated Hemoccult II test may be followed by investigation of only those patients with a positive retest. Such a procedure will reduce the work-load by 60 per cent without reducing sensitivity.     

Diagnosis and management of esophageal perforations.

Esophageal perforation remains a difficult diagnostic and management problem. Recommendations regarding treatment remain controversial. A 15-year experience with perforation of the esophagus from all causes was reviewed at Louisiana State University and Veterans Administration, Medical Centers (Shreveport, LA). The majority of the injuries involved the thoracic esophagus (28 or 54%), followed by the cervical (21 or 40%), and the intraabdominal esophagus (3 or 6%). Iatrogenic causes constituted most of the injuries (52%), followed by external trauma (23%), barogenic rupture (15%), and ingested foreign bodies (10%). Diatrizoate methylglucamine 66 per cent, sodium diatrizoate 10 per cent (Gastrografin; Squibb, Princeton, NJ) contrast studies and flexible esophagoscopy were performed in 44 and 22 patients, respectively. In the cervical esophagus, contrast studies were more sensitive and specific than endoscopy (P less than .01), but both studies were equally effective as diagnostic methods in thoracic perforations. Cervical perforations were treated with either drainage alone (7 patients) or primary repair with drainage (14 patients) with an operative mortality of 4.8 per cent. Several procedures were used in thoracic perforations, which carried a mortality of 36 per cent and were more lethal than cervical tears (P less than 0.2). Any thoracic esophageal perforation treated more than 24 hours after the onset of symptoms, irrespective of what procedure was used, was associated with a significantly higher mortality than if operated on earlier (P less than .001). Five patients with perforated carcinomas were treated by esophageal resection with no mortality. Significantly higher mortality was seen with a delay in diagnosis, thoracic perforations, and Boerhaave's Syndrome. A subset of patients with perforated carcinomas may benefit from esophageal resection with delayed reconstruction.