Perforation of the bile duct caused by endoscopic papillary large balloon dilation: A case report.

The patient was a woman in her 70s with multiple large biliary stones. Lithotripsy was attempted after endoscopic papillary large balloon dilatation. During balloon dilation, inflator resistance, and body movement due to patient pain were observed, and maximum pressure was required for the disappearance of the balloon waist. A bile duct perforation was observed when the balloon was deflated. Computed tomography after endoscopic retrograde cholangiopancreatography showed free air from the duodenal peritoneum to the right retroperitoneum. The patient was conservatively treated with nasobiliary drainage. Endoscopic large balloon dilatation is useful for large bile duct stones that are difficult to remove using endoscopic sphincterotomy alone or endoscopic papillary balloon dilation. Perforation is a potentially fatal adverse event; therefore, imaging of the intrapancreatic bile ducts should be performed before endoscopic retrograde cholangiopancreatography and attention should be paid to the balloon dilation method.

A case of gastrointestinal perforation following transarterial embolization for an intramural hematoma after cold snare polypectomy of an adenoma in the transverse colon.

We encountered a case of a large hematoma developing with perforation shortly after a cold snare polypectomy for a colorectal adenoma. The patient underwent cold snare polypectomy for a 3-mm type Is lesion in the transverse colon at another facility. Two hours later, she visited the emergency room due to abdominal pain. Contrast-enhanced computed tomography revealed a 70 mm, high-intensity mass in the transverse colon with contrast extravasation. We attempted transcatheter arterial embolization to stop the bleeding. Several hours later, the anemia had not worsened, but the severe abdominal pain persisted. Urgent laparoscopic right hemicolectomy was performed due to the possibility of gastrointestinal perforation. The surgery was successfully completed. Pathology reports confirmed the presence of an intramural hematoma in the proximal transverse colon with hemorrhagic infiltration of all layers, along with extensive ischemic changes. A perforation was identified in this area, with mucosal defects observed near the hole, possibly due to cold snare polypectomy.

Oral Extrusion of a Screw After Anterior Cervical Spine Plating: A Case Report.

Although anterior cervical discectomy and fusion (ACDF) is one of the most common surgical procedures performed for the treatment of cervical disease, it is associated with a variety of postoperative complications. Esophageal perforation is a rare but very serious post-ACDF complication, and cases in which screws extrude through the mouth are even rarer. Herein, we present the case of a 61-year-old woman who visited our emergency center with oral extrusion of a screw 6 months after undergoing ACDF. Although diagnostic imaging did not confirm esophageal perforation, the oral extrusion of the screw was clear evidence of the complication. To the best of our knowledge, this is the first reported case of oral screw extrusion without confirmed esophageal injury. This case suggests that screw migration and esophageal perforation can occur depending on the patient's underlying condition, and if the symptoms are mild, conservative treatment alone may be sufficient to treat the perforation.

Endoscopic Double Flap Tympanoplasty.

Aim: This study is aimed to compare the outcomes of the two techniques (endoscopic single flap tympanoplasty- ESFT versus endoscopic double flap tympanoplasty - EDFT) of endoscopic tympanoplasty for repairing large tympanic membrane (TM)perforations with limited anterior remnant. Methodology: In this randomised controlled trial, forty patients with large sized TM perforations were included and randomised in the ESFT and EDFT arms with twenty patients in each group. Both the groups underwent endoscopic tympanoplasty using temporalis fascia graft. The graft uptake rates and hearing results were compared. Results: Graft success rate was 85% (17/20 cases) in the ESFT group and 90%(18/20 cases) in the EDFT group. The ABG (air-bone gap) improvement median with interquartile range(IQR) was 5 dB (3.12 dB-10 dB) in the ESFT group and 8.75 dB (5dB-11.87 dB) in the EDFT group. The difference was not statistically significant. Conclusions: In our study, there was no statistically significant difference in the graft success rate or hearing gain in ESFT or EDFT group. Moreover, there was longer operative time and need for an extra incision while raising the anterior flap. This lack of statistically significant results in our study may be since the study has a very small sample size. Whether the same conclusion is reproducible needs to be further explored by a larger sized randomised controlled trial.

Status and Depth of Mastoid Antrum and the Pattern of Mastoid Pneumatization in Cases of Large, Subtotal Perforations and Posterosuperior Retraction Pockets (PSRP).

The present study aimed to evaluate the pneumatization status of the mastoid air cells in general with the depth and status of mastoid antrum in particular, in patients of chronic otitis media (COM). This is an observational cross-sectional study in sample size of 60 participants with large, subtotal perforation and posterosuperior retraction pocket (PSRP). Mean age with large central and subtotal perforation combined was 35.78 years, compared to 32.13 years in PSRP. Granulations seen in antrum in 71.6% and cholesteatoma observed in 15%. Mean depth of the mastoid antrum was 17.27 mm. A well pneumatized mastoid in 21.6%, diploic 28.3% and sclerotic in 50% was noted in this study. Chronic otitis media affects temporal bone pneumatization, particularly the mastoid antrum. Our findings indicate that the depth of the mastoid antrum is slightly greater in cholesteatoma cases due to bone erosion. As early intervention enhances postoperative quality of life by preserving or restoring auditory function, understanding the mastoid pneumatization and antrum depth is crucial for managing chronic otitis media effectively.

Infective endocarditis due to nasal septal perforation during home oxygen therapy.

We report a case of infective endocarditis (IE) due to nasal septal perforation during Home oxygen therapy (HOT). A 64-year-old man with a history of interstitial pneumonia (IP) and on HOT was hospitalized for dyspnea. Methicillin-sensitive Staphylococcus aureus (MSSA) was repeatedly detected in blood cultures. Echocardiography revealed tricuspid valve vegetation and regurgitation. The patient was diagnosed with IE, according to the modified Duke criteria. A full-body examination revealed nasal septal perforation and MSSA was isolated from the nasal cavity. The patient was treated with cefazolin and clindamycin. However, he developed aspiration pneumonia and subsequently died. The portal of entry of MSSA was damaged nasal mucosa, caused by dryness and curettage of the dried nasal mucus during HOT. Nasal septal perforation, a potential complication of HOT, may cause severe bacterial infections. Consequently, diligent nasal care is crucial during HOT.

Surgery for non-Meckel's small-bowel diverticular perforation: two case reports and a literature review.

BACKGROUND: Similar to colonic diverticula, small-intestinal diverticula are often asymptomatic, but may cause life-threatening acute complications. Non-Meckel's small-bowel diverticular perforation is rare, and the rate of mortality is high. However, there is currently no consensus regarding its therapeutic management. CASE PRESENTATION: Case 1: A 73-year-old Japanese man with localized lower abdominal pain was referred to our hospital. Enhanced computed tomography (CT) revealed diverticulitis of the small intestine, which was managed conservatively. Four days after admission, abdominal pain worsened, and repeat CT revealed extraintestinal gas. Emergency surgery was performed for the segmental resection of the perforated jejunum with anastomosis. Case 2: A 73-year-old Japanese woman was transferred to our hospital with small-bowel perforation. CT revealed scattered diverticula in the small intestine and extraintestinal gas around the small-intestinal diverticula. Emergency surgery was performed for the segmental resection of the perforated jejunum with anastomosis. CONCLUSIONS: Conservative treatment for small-bowel diverticular perforation may be attempted in mild cases; however, surgical intervention should not be delayed. Segmental resection of the affected intestinal tract with an anastomosis is the standard treatment. Residual diverticula should be documented because of the possibility of diverticulosis recurrence.

Challenges in the diagnosis and management of dry tamponade.

Dry tamponade is a rare complication of percutaneous coronary intervention. It encompasses a heterogenous pathophysiology and is used to describe hemodynamic compromise secondary to a coronary artery perforation, without free-flowing fluid in the pericardium. Tamponade physiology can result from compressive epicardial, intramyocardial, subepicardial hematomas, or dissecting intramyocardial hematomas. The diagnosis of dry tamponade requires hemodynamic derangement in the context of a compressive hematoma as demonstrated by imaging. Although echocardiography can often help identify dry tamponade, additional studies including right heart catheterization, computed tomography, or cardiac magnetic resonance imaging can inform the exact mechanism and help guide management. This article describes a case of dry tamponade, reviews the existing literature on the topic, and offers expert recommendations on diagnosis and management.

A Vascular Plug for Persistent Shock Following Transcatheter Mitral Valve Replacement.

A 78-year-old woman with severe bioprosthetic mitral valve degeneration underwent successful transcatheter mitral valve replacement with a valve-in-valve procedure. This case postprocedure was complicated by cardiogenic shock from left ventricular perforation and underscores the importance of the accurate assessment and treatment of patients following transcatheter valvular procedures.

Mesenchymal stem cells suppress inflammation by downregulating interleukin-6 expression in intestinal perforation animal model.

Introduction: Intestinal perforation has significant fatality due to sepsis contamination and prolonged inflammation. Studies showed that mesenchymal stem cells (MSCs) secreted cytokines and growth factors to reduce inflammation. This study aims to reveal the role of MSCs in controlling inflammation in intestinal perforation wound healing by measuring interleukin-6 (IL-6) and leukocytes in injured tissue. Materials and methods: A total of 48 rat models with a 10-mm longitudinal incision at the small intestine were divided into four groups: sham, control, Treatment group 1 (T1) injected with MSC doses of 1.5×106 cells and Treatment group 2 (T2) with 3×106 cells. IL-6 expressions were determined using western blot analysis, whereas the leukocyte infiltrations were assessed using the histopathological examination. All variables were evaluated on day 3 and 7. Results: Leukocyte infiltration is significantly lower in T1 and T2 compared to control group in day 3 and 7 (P<0.05), while there were no differences between the two treatment groups. The expression of IL-6 was found to be significantly lower in the T1 and T2 groups compared to the control group on days 3 and 7 (P<0.05), with no significant differences observed between the two treatment groups. Conclusion: MSCs administration in rats with intestinal perforation reduced inflammation by controlling leukocyte infiltration and IL-6 expression.

Delayed primary skin closure reduce surgical site infection following surgery for gastrointestinal perforation: A systematic review and meta-analysis.

BACKGROUND: Following surgery for Gastrointestinal (GI) perforation, there is an increased occurrence of Surgical Site Infections (SSI). The beneficial effect of employing delayed primary skin closure (DPC) on severely contaminated incisions subsequent to surgery for GI perforation remains unverified. OBJECTIVE: To systematically evaluate the advantages of the DPC management in surgery for GI perforation. METHODS: A literature search was performed using ClinicalTrials.gov, Pubmed, Embase, Cocharane, and Web of Science identified all eligible English-language studies related to surgery for GI perforation through October 2023. Randomized clinical trials (RCTs) comparing DPC with primary skin closure (PC) in surgery for GI perforation were included. Two investigators independently performed the inclusion work, and a third investigator was consulted for resolving conflicts. Data were extracted by multiple independent investigators and pooled in a random-effects model. The primary outcome was SSI, defined in accordance with the original studies. The secondary outcome was the length of stay (LOS). RESULTS: Final analysis included 12 RCTs which included a total of 903 patients were randomizing divided into either DPC or PC, including 289 patients with gastroduodenal perforation (32%), 144 patients with small intestine perforation (15.96%), 60 patients with colon perforation (6.64%), and 410 patients with appendix perforation (45.4%). The rates of SSI was significantly decreased after DPC management (OR:0.31, 95%CI:0.15-0.63, p < 0.01), no significant differences were observed between the DPC group and PC group in terms of LOS (MD: - 0.37, 95% CI: - 1.91-1.16, p = 0.63). CONCLUSION: These results point to the efficacy of DPC management in reducing SSI in patients under surgery for GI perforation, and this strategy did not increase the LOS. This systematic review and meta-analysis may contribute to informed decision-making in the management of severely contaminated wounds associated with GI perforation.

Not your typical abdominal pain: Case report of a fisherman presenting to the trauma & emergency surgery department with intestinal perforation due to an eel fish.

BACKGROUND: Traumatic intestinal perforation by foreign bodies is rare, with cases involving live fish being exceedingly uncommon, with only one reported case to date. We present a unique case of a 55-year-old fisherman who presented to the Emergency Department with traumatic intestinal perforation due to an eel fish accidentally entering his rectum. Despite initial reluctance to seek medical attention, prompt intervention was crucial to addressing peritonitis. CASE PRESENTATION: The patient presented with severe abdominal pain and signs of peritonitis. X-ray findings confirmed pneumoperitoneum. Urgent laparotomy revealed a live eel fish and a 5 cm sigmoid colon perforation, necessitating a sigmoid colostomy. DISCUSSION: Early recognition of traumatic intestinal perforation is vital for prompt management. Diagnosis can be challenging, emphasizing the need for thorough history-taking and imaging. Surgical intervention aims to repair the intestinal perforation, prevent complications and promote healing. CONCLUSION: This case highlights the importance of considering unusual causes of abdominal pain, particularly in relevant occupational history. Prompt surgical intervention is crucial for favorable clinical outcomes.

A delayed presentation of traumatic diaphragmatic hernia in a young male: a unusual case report and comprehensive review of literature.

Acquired diaphragmatic hernia is typically caused by blunt trauma to the abdomen. It can be challenging to diagnose in acute cases due to a wide range of symptoms. Delayed presentation of traumatic diaphragmatic hernia is uncommon and can lead to respiratory issues or bowel complications like incarceration, perforation, or strangulation. Computed tomography is the preferred diagnostic tool. For acute case, laparotomy is indicated traditionally; however, the choice of surgery is dependent upon the surgeon's expertise and availability of resources.

On The Use of a Sticky Bone Substitute in the Presence of a Ruptured Schneider Membrane During Sinus Lift Procedures - An Experimental Within-Rabbit Study.

PURPOSE: To assess the efficacy and safety of a sticky dual-phase porcine-derived bone substitute, compared to a similar non-adhesive graft, in addressing induced perforations of the Schneider membrane during sinus lift using a within-subject design rabbit model. MATERIALS AND METHODS: Bilateral sinus floor elevations were performed in 12 rabbits. The sinus mucosa was intentionally perforated using a blade on both sides and randomly filled with either a cortico-cancellous bone embedded in a 20% thermosensitive gel (GTO sticky bone test) or a cortical cancellous bone and 10% collagen (mp3 control). Healing progress was evaluated after 2 and 10 weeks in 6 animals at each time-point, with cone-beam computed tomography (CBCT), micro-computed tomography (microCT) and histological assessments. RESULTS: One animal of the 2-week group died but was substituted. No other complications were observed. At 2-week, on CBCTs, biomaterials particles were observed in the vicinity of the Schneider membrane in two out of six sinuses of each group, but never dispersed into the sinus. MicroCT and histology consistently revealed few granules beyond the elevated region. Histologically, five sinuses in the mp3 group and two sinuses in the GTO group exhibited granules outside the elevated region but in the vicinity of the perforations. In the 10-week groups, the number of affected sinuses decreased to one in the mp3 group and two in the GTO group. Throughout all observations, the graft granules consistently resided proximate to the elevated region. Micro-CT demonstrated a reduction in the volume of the elevated region by approximately 12% after 2 weeks and 50-54% after 10 weeks. CONCLUSIONS: The use of both sticky and non-sticky bone substitutes seems to prevent a substantial amount of particles from extruding through an induced perforation of the Schneiderian membrane. This suggests that it could be possible to use a sticky bone as an alternative to a barrier membrane to avoid the extrusion of bone granules in the presence of accidental perforation of the sinus membrane in clinical practice. After 10 weeks of healing, the volume of the elevated region decreased by approximately 50%, possibly due to biomaterial resorption and loss through the surgically created perforation.

Osseodensification technique in crestal maxillary sinus elevation-A narrative review.

Osseodensification is a novel approach that has significantly advanced the field of implant dentistry, particularly in the context of transcrestal maxillary sinus floor elevation. This technique involves the use of specially designed burs that compact and densify bone along the osteotomy walls, thereby enhancing implant primary stability and facilitating osseointegration in low-density bone. This article reviews the historical evolution of implant site preparation, and the biomechanical, histological, and clinical evidence of osseodensification with a special focus on its application in sinus floor augmentation. The integration of this technique into contemporary practice represents a paradigm shift, offering a minimally invasive and efficient solution for addressing the challenges of posterior maxilla, with improved patient-reported outcomes and low complication rate. Three different protocols for sinus lift and implant placement using osseodensification burs are proposed based on available literature, and risk factors for Schneiderian membrane perforation based on residual bone height are discussed, along with implant-related outcomes and patient-reported outcome measures. The potential for osseodensification to become a standard practice in sinus floor augmentation is emphasized, highlighting key aspects such as surgical protocol and patient selection.

Acute Renal Failure and Generalized Weakness in a 75-Year-Old Male With Pauci-Immune Necrotizing Antineutrophil Cytoplasmic Antibody (ANCA)-Associated Vasculitis: A Case Report.

We describe a 75-year-old male who presented to the emergency department with generalized weakness and was ultimately diagnosed with acute renal failure secondary to pauci-immune necrotizing antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The patient's clinical course was complicated by a perforated gastric ulcer and severe malnutrition, necessitating involvement from multiple specialists. The case highlights the challenges of this rare vasculitis and the complications that can arise from the disease and its treatment. .

Evaluation of Maxillary Sinus Septa Using Cone Beam Computed Tomography (CBCT): A Retrospective Study.

BACKGROUND: Maxillary sinus septa, which are bony structures dividing the sinus cavity, can pose challenges during sinus lift or implant surgeries by potentially causing perforation of the Schneiderian membrane. This study aimed to estimate the prevalence, height, location, orientation, and risk of perforation of the maxillary sinus septa using cone beam computed tomography (CBCT). MATERIALS AND METHODS: This retrospective, cross-sectional study utilized CBCT (NewTom CBCT machine, of which the scan parameters were 90 KvP, 8 mAs, and 14 s exposure with a field of view (FOV) of 8×8 cm and a 0.2 mm3 voxel size) images of 300 maxillary sinuses from patients aged >18 years, obtained from Swami Devi Dyal Hospital and Dental College in Panchkula, India. Scans were analyzed for the presence, height, location, orientation, and risk of septal perforation. The data were categorized based on age, sex, and dentition status. Statistical analyses were performed to assess the prevalence, configuration, and risk factors. RESULTS: The prevalence of maxillary sinus septa was 21.33%, with the majority showing a single septum (90.63%). Septa were predominantly found in the middle region (48.44%), with bucco-palatal orientation (93.75%) being more common than anteroposterior. The mean septa height was 6.16 mm. The perforation was classified as moderate (48.4%), low (46.8%), or high (4.6%). Class III septa were associated with the highest risk of perforation. CONCLUSION: This study highlights a significant prevalence of maxillary sinus septa with variations in height, orientation, and location. The risk of perforation varies with the septa configuration and orientation. CBCT is essential for identifying these anatomical features to minimize surgical complications and to guide preoperative planning.

Perforated Meckel's diverticulum in an adult: Case report and literature review.

INTRODUCTION AND IMPORTANCE: Meckel's diverticulum (MD) is an unusual clinical condition that occurs in approximately 2-4 %. The complications are more common in children, with a low prevalence in adults, with the main complication in adults being intestinal obstruction followed by diverticulitis with or without perforation. CASE PRESENTATION: We present a 30-year-old female patient with a history of an appendectomy. She attends the emergency room due to a four-day history of pain in the lower abdominal quadrants, tachycardia, and leukocytosis, with an abdominal CT scan identifying an inflammatory process of the ileum, suggesting a Meckel's diverticulum, urachus remnant, or foreign body. The patient was taken to surgery, and inflammatory adhesions, including a perforated Meckel's diverticulum with necrotic signs and purulent production, were evidenced. Intestinal resection and ileal anastomosis were performed with no complications at 90 days. CLINICAL DISCUSSION: Preoperative diagnosis is difficult in cases with associated inflammatory conditions and is generally made incidentally during surgery and less frequently with CT scans. Surgical management for patients with MD is still controversial and depends on many factors, including symptoms, related complications, characteristics of the diverticulum, and the patient's clinical condition. Currently, no standardized surgical technique exists, and cases should be individualized. CONCLUSION: Meckel's diverticulum perforation is a rare complication in the adult population and remains a diagnostic and surgical challenge, and the final decision must be individualized.

Traumatic Tympanic Membrane Perforation in Children: A Descriptive Cross-sectional Study.

INTRODUCTION:   TTraumatic perforation of the tympanic membrane in pediatric population is often encountered in primary  otolaryngologic clinics or in the emergency department. The objective of the  study was to find out the clinical presentation of traumatic tympanic membrane perforation in the pediatric population. METHODS: A cross-sectional study was done from February, 2023 to February, 2024 after obtaining the ethical approval from the Institutional Review Board (2023/114). All the patients aged less than 18 years and presenting with traumatic tympanic membrane perforation were included in the study. Collected data was entered and analysed using Microsoft Excel. Patients were evaluated for demographics, mechanism of trauma and clinical characteristics of ear drum perforation in children. RESULTS: A total of 384 children aged less than 18 years were included in the study among which 267 (69.53%) were males. Physical assault 109 (28.39%) was the most common cause of tympanic membrane perforation. The most common symptom at the time of presentation was ear block/hearing loss 208 (54.16%). Conductive hearing loss was present in 214 (55.73%) children. CONCLUSION: Traumatic perforation of the tympanic membrane resulted mostly from the blunt force trauma especially in male children.

Effectiveness of surgical approach in the management of non-traumatic corneal perforations.

CLINICAL RELEVANCE: Non-traumatic aetiologies are one of the leading causes of corneal perforations. The management of corneal perforation is quite challenging and complex for anterior segment surgeons. The appropriate surgical approach for each case is usually determined on the basis of a combination of many different parameters. BACKGROUND: The study aimed to evaluate surgical approach options and outcomes in the treatment of non-traumatic corneal perforations. METHODS: Patient data who underwent surgery for non-traumatic corneal perforation between 2016 and 2023 were retrospectively evaluated. Medical records were assessed in terms of age, gender, perforation aetiology, the first and last examination notes, surgical approach, follow-up time, and additional surgeries and outcomes according to anatomical, therapeutic and functional success. Anterior segment photographs were investigated for thorough explanation of the examinations. RESULTS: Forty-five eyes of 45 patients were included (mean age 61.2 ± 22.4 (90-2), female/male ratio 20/25). Surgical approaches applied according to the size and location of the perforation site included fibrin glue application (6), amniotic membrane transplantation (AMT) (9), corneal patch graft application(15), and tectonic keratoplasty (15). The ratio of inflammatory and infectious causes as the two main indications was 29/16. Globe integrity was ensured with the first surgery in 27 eyes. However, 17 eyes required secondary surgical attempts due to failure of the first approach and 1 eye underwent evisceration. AMT was the least successful method among other methods in anatomical, therapeutic, and functional assessment. CONCLUSION: There are various surgical approaches for repairing non-traumatic corneal perforations, each with its own advantages and disadvantages. These include high tissue resistance, the ability to remove necrotic tissue, ease of access, and anti-inflammatory activity. It is possible to successfully repair corneal perforations with single and combined methods, considering the above-mentioned features, especially depending on the size and location of the defect. While AMT is a viable and time-saving choice - especially in the lack of donor tissues - further interventions are necessary in most circumstances.