Outcome and predictive factors for perforation in orthodontic rubber band-assisted endoscopic submucosal dissection of fibrotic colorectal lesions.

Endoscopic submucosal dissection (ESD) of fibrotic colorectal lesions is difficult and has a high complication rate. There are only a few reports on the utility of orthodontic rubber band (ORB) traction in reducing the difficulty of this procedure. This study aimed to investigate the risk factors for perforation when applying ORB traction during ESD of fibrotic colorectal lesions. We continuously collected the clinical data of 119 patients with fibrotic colorectal lesions who underwent ESD with ORB and clip traction between January 2019 and January 2024. Possible risk factors for perforation were analyzed. The median ORB-ESD operative time was 40 (IQR 28-62) min, and the en bloc and R0 resection rates were 94.1% and 84.0%, respectively. Perforation occurred in 16 of 119 patients (13.4%). The lesion size, lesion at the right half of the colon or across an intestinal plica, the degree of fibrosis, operation time, and the surgeon's experience were associated with perforation during ORB-ESD (P < 0.05). Multivariate logistic regression analysis showed that lesions in the right colon (OR 9.027; 95% CI 1.807-45.098; P = 0.007) and those across an intestinal plica (OR 7.771; 95% CI 1.298-46.536; P = 0.025) were independent risk factors for perforation during ORB-ESD. ORB-ESD is an effective and feasible approach to treat fibrotic colorectal lesions. Adequate preoperative evaluation is required for lesions in the right colon and across intestinal plicas to mitigate the risk of perforation.

Late anastomotic perforation of the ileum 3 years after intestinal resection.

Late perforation of the ileum is a rare and potentially life-threatening complication following intestinal resection. We present a unique case of a woman in her 60s with a history of appendiceal carcinoid tumour, who underwent a right hemicolectomy. Positron emission tomography and surveillance CTs showed normal surgical changes and no recurrent malignancy. Three years postoperatively, she presented with severe abdominal pain. CT revealed a perforation along the ileal wall of the ileocolonic anastomosis. She underwent emergent resection and repeat ileocolonic anastomosis. We conclude that the patient had subclinical ischaemia of the anastomosis, which eventually progressed to perforation 3 years later. We discuss a literature review on late small intestinal anastomotic perforations and their associated risk factors. Our case and literature review emphasise the importance of considering delayed anastomotic leak in postoperative patients with a history of intestinal cancer, inflammatory bowel disease, Roux-en-Y enteroenterostomy or side-to-side anastomosis.

A case of small bowel evisceration through the rectum and anus.

A 46-year-old man presented with a small bowel prolapsing through the anus after straining on the toilet, which was starting to become ischaemic. He admitted to inserting a plastic object in his rectum about half an hour before straining. The bowel was kept moist by placing an intravenous drip line with saline dripping onto a wet swab. In theatre, the bowel was found to be prolapsing through a hole in the upper rectum and out through the anus. It was reduced back into the abdominal cavity through the same perforation, which was 4 cm long, without needing to extend it. This was sutured with polydioxanone (PDS) 2-0 as there was no contamination with faeces or pus. Due to improvement in the appearance of a small bowel and an extremely bruised mesentery, a re-look was planned in 24 hours. At the re-look the small bowel appeared healthy, therefore no resection was performed. However, a loop colostomy was fashioned to protect the upper rectal perforation repair. This shows that resection is not always required in such cases.

Diagnosis and management of type II endoscopic retrograde cholangiopancreatography-related perforations: a multicenter retrospective study.

BACKGROUND: The management of type II endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is still controversial. This study aimed to compare the effects of covered self-expandable metallic stent (SEMS), surgery, and conservative treatment for type II perforation. METHODS: From January 2010 to December 2021, this study collected relevant data from five large hospitals in China. The data of ERCP difficulty grading and ERCP-related perforation in 26,673 cases that underwent ERCP during 11 years were retrospectively analyzed. Of 55 patients with type II perforation, 41 patients were implanted with a biliary covered SEMS (stent group), 10 underwent surgery (surgery group), and 4 received conservative treatment (conservative group). RESULTS: Among the 55 patients with type II perforation, ERCP and computed tomography diagnostic rates of type II perforation were 10.91% (6/55) and 89.09% (49/55), respectively. The incidence of type II perforation in grade 5 ERCP (0.43%, 11/2,537) was significantly higher than that in grade 1-3 ERCP (0.16%, 32/19,471). (P = 0.004) and grade 1-4 ERCP (0.26%,12/4,665) (P = 0.008), respectively. Among the 10 patients in the surgical group, primary repair was performed in only 7 patients in whom location of the perforation could be identified. The incidence of retroperitoneal abscess was significantly lower in the stent group than in the surgery group (P = 0.018) and the conservative group (P = 0.001), respectively. The average hospital stay in the stent group was shorter than that in the surgery group (P = 0.000) and conservative group (P = 0.001), respectively. CONCLUSIONS: The incidence of type II perforation was dependent on the degree of difficulty of ERCP. The treatment of type II perforation with a covered SEMS can significantly reduce the incidence of retroperitoneal abscess and shorten the hospital stay, with better results than surgical and conservative treatments.

Endoscopic suturing and clipping devices for defects in the GI tract.

Gastrointestinal luminal defects, including perforations, leaks and fistulae, pose persistent obstacles in endoscopic therapeutic interventions. A variety of endoscopic approaches have been proposed, with through-the-scope clipping (TTSC), over-the-scope clipping (OTSC) and suturing representing the main techniques of tissue apposition. However, the heterogeneity in defect morphology, the technical particularities of different locations in the gastrointestinal (GI) tract and the impact of various parameters on the final outcome, do not allow distinct conclusions and recommendations on the optimal approaches for defect closure, and, thus, current practice is based on endoscopists experience and local availability of devices. This review aims to collect the existing evidence on tissue apposition devices, in order to outline the role of every device on specific indications.

The role of radiology in diagnosing gastrointestinal tract perforation.

Spontaneous, iatrogenic or surgical perforation of the whole gastrointestinal wall can lead to serious complications, resulting in increased morbidity and mortality. Optimal patient management requires early clinical appraisal and prompt imaging evaluation. Both radiologists and referring clinicians should recognize the importance of choosing the ideal imaging modality and the usefulness of oral and rectal contrast medium. Surgeons and radiologists should be familiar with CT and fluoroscopy findings of the normal and pathologic anatomy after esophageal, stomach or colon surgery. Specifically, they should be able to differentiate innocuous from clinically-relevant, life-threatening postoperative complications to guide appropriate treatment. Advantages of esophagram, CT-esophagram, CT after rectal contrast enema and other imaging modalities are discussed.

Colonoscopic removal of an intrauterine device with rectal perforation: A case report.

RATIONALE: The intrauterine device is one of the effective, safe, convenient, economical, and reversible contraceptive methods. Although its contraceptive effect is definite, some female patients may experience complications such as expulsion, bleeding, and pregnancy with the device in place. Rectal perforation is one of the rare and serious complications, which can lead to complications such as abdominal infection and intestinal adhesions, severely affecting the quality of life of patients. PATIENT CONCERNS: A 34-year-old female was sent to the Department of Gastroenterology with noticeable left lower quadrant abdominal pain. She had presented with abdominal discomfort and anal tenesmus 1 year earlier. Two months ago, her abdominal pain had gradually worsened and she was presented to our hospital. DIAGNOSES: Investigations, including colonoscopy and computed tomography scan, had revealed an intrauterine device migrated and perforated into the rectum. INTERVENTIONS AND OUTCOMES: The patient underwent successful colonoscopic removal of the intrauterine device. She recovered well after the treatment. LESSONS: This case proves that endoscopic therapy can be considered the preferred method for removing intrauterine devices displaced into the digestive tract lumen.

Preoperative high dose of dexamethasone in emergency laparotomy: randomized clinical trial.

BACKGROUND: Patients undergoing emergency laparotomy present with a profound inflammatory response, which could be an independent pathophysiological component in prolonged recovery. The aim of this study was to investigate the effects of a single preoperative high dose of intravenous dexamethasone on the inflammatory response and recovery after emergency laparotomy. METHODS: In this double-blinded placebo-controlled trial, patients were prospectively stratified according to surgical pathology (intestinal obstruction and perforated viscus) and randomized to preoperative 1 mg/kg dexamethasone or placebo at a ratio of 1 : 1. The primary outcome was C-reactive protein on postoperative day 1. Secondary outcomes were postoperative recovery, morbidity, and mortality. RESULTS: A total of 120 patients were included in the trial. On postoperative day 1, the C-reactive protein response was significantly lower in the dexamethasone group (a median of 170 versus 220 mg/l for dexamethasone and for placebo respectively; P = 0.015; mean difference = 49 (95% c.i. 13 to 85) mg/l) and when stratified according to intestinal obstruction (a median of 60 versus 160 mg/l for dexamethasone and for placebo respectively; P = 0.002) and perforated viscus (a median of 230 versus 285 mg/l for dexamethasone and for placebo respectively; P = 0.035). Dexamethasone administration was associated with improved recovery (better haemodynamics, better pulmonary function, less fatigue, and earlier mobilization). Furthermore, the dexamethasone group had a lower 90-day mortality rate (7% versus 23% for dexamethasone and for placebo respectively; relative risk 0.33 (95% c.i. 0.11 to 0.93); P = 0.023) and a decreased incidence of postoperative major complications (27% versus 45% for dexamethasone and for placebo respectively; relative risk 0.62 (95% c.i. 0.37 to 1.00); P = 0.032). CONCLUSION: A single preoperative high dose of intravenous dexamethasone significantly reduces the inflammatory response after emergency laparotomy and is associated with enhanced recovery and improved outcome. REGISTRATION NUMBER: NCT04791566 (http://www.clinicaltrials.gov).

Cholestyramine crystal deposits as a possible cause of small bowel perforation.

This is a case report of a 70-year-old woman with possible cholestyramine-induced bowel perforation. She had a prior history of pancreaticoduodenectomy for pancreatic cancer with a daily intake of cholestyramine. She underwent emergency laparotomy for small bowel perforation twice. Subsequent pathology reports showed crystal depositions in the small bowel wall. Leasions spread out on the small bowel and the omentum during the second surgery were thought to be carcinomatosis. However, the pathology report showed no malignant cells but plenty of crystal depositions as seen with cholestyramine intake.

Perforation of Jejunal Metastasis from Primary Lung Carcinoma with Brain Metastasis: A Rare Case.

A case describes a 49-year-old male patient who underwent emergency exploratory laparotomy for small intestinal perforation. Peritonitis was present due to perforation of the jejunal tumor. Resection of the jejunal tumor with perforation was performed followed by end-to-end anastomosis of the jejunum. The resected jejunal tumor was identified in the histopathological examination as metastatic from a clear cell variant of squamous cell/large cell carcinoma of the lung. It was associated with metastatic lesions in the brain. Metastasis from the lung carcinoma in the jejunum is a very rare condition predisposing to small intestinal perforation which is also associated with brain metastasis.

Iatrogenic rectal perforation after coccygeal radiofrequency ablation.

Coccygodynia (pain of the coccygeal bone) can be treated locally with anti-inflammatory drugs, local steroid injections, surgical removal of the coccyx and, more recently, with radiofrequency thermal ablation. Complications, such as perforation of the colon, can occur as a consequence of the close relationship between the rectum and the sacrococcyx and with the heat from the thermal ablation expanding to the surrounding tissue causing delayed damage with severe consequences. The treatment of this complication requires the combined effort of the gastrointestinal surgeon as well as a gastroenterologist. In this case report, we describe the treatment of this complication and the clinical course after a perforation of the rectum due to thermal ablation of the coccyx to treat long-standing coccygodynia.

Placement of a drainage tube in the ileac lumen following laparoscopic appendectomy: A case report and literature review.

RATIONALE: Ileal perforation caused by the insertion of a drainage tube is a rare complication. Hence, the utilization of surgical drains in abdominal surgery remains controversial. At present, there is a trend to reduce the utilization of drains in abdominal surgery, although certain situations may necessitate their application. PATIENT CONCERNS: A 25-year-old Chinese woman presented with a history of right lower abdominal pain persisting for 10 days. Imaging examinations, including abdominal computed tomography and ultrasound, identified low-density lesions measuring 10 × 8 × 8cm3 in the right lower abdomen, which are consistent with perforated appendicitis complicated by a peri-appendiceal abscess. A laparoscopic appendectomy was carried out. On the 5th postoperative day, the drainage fluid changed to a grass-green color (80mL). Imaging with retrograde contrast through the drainage tube revealed that the 26 Fr silicon rubber drainage tube tip was positioned 50cm away from the ileocecal junction within the ileum. Both the ileal and ileocecal regions appeared well-developed. INTERVENTION AND OUTCOMES: Oral intake was suspended, and the patient received antacids, somatostatin, antibiotics, and total parenteral nutrition. On the 19th postoperative day, a follow-up imaging procedure using retrograde contrast through the drainage tube indicated that the tube tip was sealed. The treatment concluded on day 33 postoperatively, and the patient was discharged. DISCUSSION AND CONCLUSION: Ileal perforation due to an abdominal drainage tube following laparoscopic appendectomy constitutes a rare but serious complication. However, due to the adhesion and inflammatory changes around the abscess, laparoscopic dissection becomes a challenging and risky process, and the surgical skills and experiences are particularly important. Removing the abdominal drainage tube promptly based on the characteristics of the drainage fluid is recommended. The findings provide valuable insights for surgeons navigating similar challenges.

Surgical repair of endoscopy-induced colonic perforations: a case-matched study of short-term morbidity and mortality.

BACKGROUND: Our aim was to describe the clinical outcomes of surgical interventions performed for the management of colonoscopy-related perforations and to compare these outcomes with those of matched colorectal surgeries performed in elective and emergency settings. METHODS: We included patients with endoscopic colonic perforation who underwent surgical intervention from the 2014-2017 National Surgery Quality Improvement Program participant use data colorectal targeted procedure file. The primary outcome in this study was short term surgical morbidity and mortality. Patients (group 1) were matched with 1:2 ratio to control patients undergoing same surgical interventions for other indications on an elective (group 2) or emergency basis (group 3). Bivariate analysis was conducted to compare categorical variables between the three groups, and multivariate logistic regression was used to evaluate the association between the surgical indication and 30-day postoperative outcomes. RESULTS: A total of 590 patients were included. The average age of the patients was 66.5±13.6 with female gender predominance (381, 64.6%) The majority of patients underwent open colectomy (365, 61.9%) while the rest had suturing (140, 23.7%) and laparoscopic colectomy (85, 14.4%). Overall mortality occurred in 4.1% and no statistically significant difference in mortality was found between the three techniques (P=0.468). Composite morbidity occurred in 163 patients (27.6%). It was significantly lower in laparoscopic colectomy (14.1%) compared to 30.2% and 29.4% in open colectomy and suturing approaches (P=0.014). Patients undergoing colectomy for iatrogenic colonic perforation had less mortality, infection rates and sepsis, as well as bleeding episodes compared to those who had colectomy on an emergent basis. Outcomes were comparable between the former group and patients undergoing elective colectomy for other indications. CONCLUSIONS: Surgical management of colonoscopy related perforations is safe and effective with outcomes that are similar to that of patients undergoing elective colectomy.

Rectal perforation after laser hemorrhoidoplasty: a case report.

This case report outlines the intricate management of rectal perforation following laser hemorrhoidoplasty in a 31-year-old female, leading to an acute abdomen, sepsis, and multiorgan failure. Urgent laparoscopic exploration and the establishment of a double-loop colostomy were undertaken, marking the beginning of a complex course characterized by relapsed pelvic sepsis. Laser hemorrhoidoplasty has gained widespread acceptance for its minimally invasive approach in treating hemorrhoids. Remarkably, to our knowledge, the case we present is the first major complication reported after laser hemorrhoidoplasty, likely attributed to collateral thermic and mechanical tissue damage.

Evaluation of laparoscopic peritoneal lavage for perforated diverticulitis: a national registry-based study.

BACKGROUND: Laparoscopic lavage (LPL) has been suggested for treatment of non-feculent perforated diverticulitis. In this observational study, the surgical treatment of diverticular disease in Sweden outside prospective trials was investigated. METHODS: This population-based study used the National Patient Register to identify all patients in Sweden with emergency admissions for diverticular disease, as defined by ICD codes from July 2014 to December 2020. Demographics, surgical procedures and outcomes were assessed. In addition, register data since 1997 were retrieved to assess co-morbidities, previous abdominal surgeries, and previous admissions for diverticular disease. RESULTS: Among 47 294 patients with emergency hospital admission, 2035 underwent LPL (427 patients) or sigmoid resection (SR, 1608 patients) for diverticular disease. The mean follow-up was 30.8 months. Patients selected for LPL were younger, healthier and with less previous abdominal surgery for diverticular disease than those in the SR group (P < 0.01). LPL was associated with shorter postoperative hospital stay (mean 9.4 versus 14.9 days, P < 0.001) and lower 30-day mortality (3.5% versus 8.7%, P < 0.001). Diverticular disease-associated subsequent surgery was more common in the SR group than the LPL group except during the first year (P < 0.001). LPL had a lower mortality rate during the study period (stratified HR 0.70, 95% c.i. 0.53-0.92, P = 0.023). CONCLUSION: Laparoscopic lavage constitutes a safe alternative to sigmoid resection for selected patients judged clinically to require surgery.

Diverticulitis is inflammation in pouches of the large bowel. Rarely, diverticulitis can lead to a bowel perforation causing peritonitis. Traditionally, it was treated by resection of the inflamed bowel with a stoma. A milder treatment has been proposed in which the abdomen is rinsed with saline laparoscopically and drained (laparoscopic lavage). This study aimed to examine the outcomes of laparoscopic lavage in Sweden. Our findings support the use of this method in younger and healthier patients with a history of no or only minor previous abdominal surgery.

[A case of small intestinal endometriosis with bowel obstruction and perforation].

A 47-year-old woman was referred to our hospital with recurring lower abdominal pain persisting for more than 2 weeks. Imaging modalities showed small bowel obstruction caused by a mass lesion in the terminal ileum. Despite undergoing fasting, rehydration, and decompression through an ileus tube, her symptoms persisted. Furthermore, the condition deteriorated on day 4, with the onset of her menstrual period. An emergency surgery was conducted on the 7th day after hospitalization. Surgical observations indicated severe stenosis around the ileocecal valve and ileal perforation approximately 40cm from the oral stricture. As a result, ileocecal resection was performed. Pathological examination revealed endometrial tissue infiltration through the mucosal lamina propria to the ileal subserosa. Thus, the patient was identified with intestinal endometriosis of the ileocecum. Endometriosis of the small bowel is an uncommon condition that eventually causes intractable bowel obstruction. Although preoperative diagnosis is considered challenging, intestinal endometriosis should be included in the differential diagnosis in cases of bowel obstruction in women of childbearing age.

Necrotizing fasciitis of the thigh secondary to perforated rectal cancer: the sciatic foramen as a route for infective spread.

Necrotizing fasciitis (NF) is a potentially life-threatening surgical emergency. It is a rapidly progressive infection of soft tissues, and mortality is related to the degree of sepsis and the general condition of the patient. It is a rare condition that requires a rapid diagnosis and surgical treatment is aggressive debridement. There are a small number of reported cases of perforation of a rectal malignancy leading to NF of the thigh. We present a case with rectal cancer in which the sciatic foramen had provided a channel for the spread of pelvic infection into the thigh.

La fascitis necrotizante es una emergencia quirúrgica potencialmente mortal. Es una infección de tejidos blandos rápidamente progresiva y la mortalidad está relacionada con el grado de sepsis y el estado general del paciente. Es una condición poco común que requiere un diagnóstico rápido, y el tratamiento quirúrgico consiste en un desbridamiento agresivo. Existe un pequeño número de casos notificados de perforación de neoplasia maligna de recto que conduce a fascitis necrotizante del muslo. Presentamos un caso de cáncer de recto en el cual el foramen ciático fue el canal para la propagación de la infección pélvica al muslo.