Management of perforations during endoscopic resection.

Despite the evolution in tools and techniques, perforation is still one of the most pernicious adverse events of therapeutic endoscopy with potentially huge consequences. As advanced endoscopic resection techniques are worldwide spreading, endoscopists must be ready to manage intraprocedural perforations. In fact, immediate endoscopic closure through a prompt diagnosis represents the first-line option, saving patients from surgery, long hospitalizations and worse outcomes. Traditional and novel endoscopic closure modalities, including clips, suturing devices, stents and vacuum therapy, are increasingly expanding the therapeutic armamentarium for closing these defects. Nevertheless, available literature on this topic is currently limited. In this review our goal is to give an overview on the management of perforations occurring during endoscopic resections, with particular attention to characteristics, advantages, disadvantages and new horizons of endoscopic closure tools.

Colorectal Oncologic Emergencies: Recognition, Management, and Outcomes.

Colorectal cancer is the third most frequent type of malignancy in the United States, and the age at diagnosis is decreasing. Although the goal of screening is focused on prevention and early detection, a subset of patients inevitably presents as oncologic emergencies. Approximately 15% of patients with colorectal cancer will present as surgical emergencies, with the majority being due to either colonic perforation or obstruction. Patients presenting with colorectal emergencies are a challenging cohort, as they often present at an advanced stage with an increase in T stage, lymphovascular invasion, and metachronous liver disease.

Duodenal Diverticular Perforation Treated Conservatively: Reassessing Indications for Treatment.

A 59-year-old woman presented with a chief complaint of melena. She had no abdominal findings, such as tenderness or tapping pain. Laboratory tests revealed a white blood cell count of 5,300 cells/µL and C-reactive protein level of 0.07 mg/dL. Inflammation and anemia (hemoglobin 12.4 g/dL) were denied. Contrast-enhanced computed tomography (CT) revealed multiple duodenal diverticula and air surrounding a descending duodenal diverticulum. Based on these findings, duodenal diverticular perforation (DDP) was suspected. Oral food intake was stopped, and nasogastric tube feeding and conservative treatment with cefmetazole, lansoprazole, and ulinastatin were begun. On day 8 of hospitalization, follow-up CT revealed the disappearance of the air surrounding the duodenum, and the patient was discharged on day 19 after the resumption of oral feeding.

Two cases of intestinal perforation due to mesenteric artery embolism during extracorporeal membrane oxygenation and intra-aortic balloon pumping.

The patient in case 1 was a 50-year-old man who presented to the emergency department of the local hospital with chest pain and syncope for 3 hours due to acute myocardial infarction. He underwent cardiopulmonary resuscitation (CPR) followed by extracorporeal membrane oxygenation (ECMO), and intestinal perforation was detected on day 9. The patient in case 2 was a 58-year-old man who was admitted to the hospital with abdominal pain lasting for 3 days. He also required CPR and ECMO for cardiogenic shock, and intestinal perforation was identified on day 7 of ECMO. We believe that this case report will be important to alert clinicians to the possibility of this complication and to encourage early detection and intervention to improve prognosis. Conventionally, the gastrointestinal tract has received secondary attention in patients receiving ECMO support because the vital organs tend to be considered first. However, this case report illustrates the importance of monitoring gastrointestinal function in patients undergoing ECMO.

Gastrointestinal complications (gangrene or perforation) after corona virus disease 2019 - A series of ten patients.

During the recent second wave of corona virus disease 2019 (COVID-19) pandemic in India, we managed a series of gastrointestinal complications in patients with COVID-19. We aim to highlight the key presentation and clinical course and emphasize the lessons we learnt from our series of such patients. A case review of ten consecutive patients with either bowel gangrene or perforation who were managed at our centre from March 20, 2021 to June 10, 2021. Clinical-demographic details, possible etiology, radiological findings, management and outcomes have been described. Of the 10 patients, 2 presented with bowel gangrene and 8 with perforation. In our series, all these patients were diagnosed with the help of computed tomography (CT) abdomen during the 3rd week after diagnosis of COVID-19. All had received steroid medication. Both patients with bowel gangrene and 4 of 8 patients with perforation underwent surgery, while 4 were managed non-operatively. Barring one patient, all the operated patients succumbed within 5 days of surgery after rapid clinical deterioration. Non-operative management in selected patients with perforation including placement of percutaneous drains, bowel rest and antibiotics was successful. Emergency surgery for COVID-19 related intestinal gangrene or perforation was associated with high mortality in our series. Non-operative management which avoids the added stress of a major emergency surgery particularly in patients just recovering from COVID-19 may be considered in stable patients in whom perforation appears to be contained.

Bowel perforation following percutaneous sclerotherapy of an intra-abdominal lymphatic malformation.

Mesenteric lymphatic malformations result from abnormal proliferation of disorganized mesenteric lymphatic channels. Sclerotherapy is often preferred over surgery as it is less invasive and has lower post-procedure morbidity. Sclerotherapy has been described as durable and effective with a low complication rate. We describe a serious complication from sclerotherapy of a lymphatic malformation extending from the mesentery through the bowel wall, highlighting the spectrum of this pathology and the need for multidisciplinary management of complex cases.

Multiple small bowel perforations due to cytomegalovirus related immune reconstitution inflammatory syndrome in an HIV patient: A case report.

RATIONALE: The presentation of multiple intestinal perforations is a severe complication of enteric cytomegalovirus (CMV) infection, sometimes associated with immune reconstitution inflammatory syndrome (IRIS) after the initiation of antiretroviral therapy (ART) in patients with human immunodeficiency virus (HIV). Here we reported a rare case of a patient with HIV infection who developed multiple perforations in the small bowel shortly after ART initiation without any prodromal gastrointestinal symptoms. We also reviewed the literature of reported cases to clarify their clinical characteristics for early diagnosis and rapid intervention. PATIENT CONCERNS: A patient with HIV presented with fever after 16 days of ART initiation and was admitted to our hospital. He was treated with intravenous ganciclovir due to persistent CMV viremia. The fever resolved 10 days later. However, he reported persistent left lower abdominal pain. DIAGNOSES: The patient was diagnosed with multiple small bowel perforations, CMV-related IRIS, and acquired immune deficiency syndrome. An upright abdominal x-ray in a tertiary level hospital revealed bilateral moderate intraperitoneal free air. We performed a pathological examination and metagenomic next-generation sequencing. CMV enteritis was confirmed by immunohistochemical staining and other opportunistic infections were excluded by metagenomic next-generation sequencing. INTERVENTIONS: The patient was treated with intravenous ganciclovir and 24 hours later, the patient underwent exploratory laparotomy. Partial resection and surgical repair of the small intestine were performed. OUTCOMES: The patient ultimately died from intestinal obstruction and septic shock 55 days after surgery. LESSONS: Perforations due to CMV-related IRIS are very rare, and usually appear shortly after ART initiation. Most cases lack the prodromal symptoms of abdominal pain and diarrhea. Intestinal perforations are lethal, and early detection and surgical treatment are lifesaving.

Case Report: Typhoid Fever Complicated by Ileal Perforation in an Urban Slum of Dhaka, Bangladesh.

Intestinal perforation is one of the most dangerous complications of typhoid fever and demands urgent hospitalization, diagnosis, and surgical management to reduce morbidity and prevent mortality. Here, we report a case of typhoidal intestinal perforation in a 19 year-old young man detected by passive surveillance during a cluster-randomized trial with Vi-tetanus toxoid conjugate vaccine (Typhoid Vaccine Acceleration Consortium: TyVAC) in an urban slum area in Mirpur, Dhaka, Bangladesh. The patient presented with a high-grade fever, lower abdominal pain, and vomiting and was admitted to a healthcare facility. Physical examination and preoperative investigations of the patient suggested a presumptive diagnosis of intestinal perforation, and the patient was transferred to a tertiary-level hospital for surgical management. A positive blood culture, intraoperative findings, and histopathology of an intestinal biopsy confirmed ileal perforation due to typhoid fever. This case report highlights the need for prompt diagnosis and appropriate pre- and postoperative management of patients who appear with the symptoms of typhoidal intestinal perforation. This report further demonstrates the importance of systematic surveillance and proper evaluation to determine the true incidence rate of typhoid fever and intestinal perforation in Bangladesh.

Severe complications of chronic cholelithiasis treatment.

BACKGROUND: Gallstone disease is a burden affecting about 15% percent of the population around the world. The complications of gallstone disease are numerous and many require emergency care. Severe complications are not uncommon and require special attention, as lethal outcome is possible. CASE PRESENTATION: We present a retrospective analysis of eight cases describing severe complications of gallstones in patients undergoing endoscopic treatment of chronic gallstones conditions. All patients were admitted to our emergency care department following symptoms onset. The diagnostic difficulties, treatment strategies and outcomes are presented. The associated risk factors and preventative measures are discussed. Two patients developed profuse bleeding, two developed acute pancreatitis, two patients had perforation related complications. One rare case of bilioma and one case of iatrogenic injury are presented. All patients had severe condition, in two cases lethal outcome was a result of co-morbidity and difficulties in management. CONCLUSION: Special care should be taken in patients with risk factors of severe complications in order to improve outcome and prevent the development of life-threatening conditions.

Recombinant Human Thrombomodulin Has Additive Effects in Septic Patients Undergoing Continuous Hemodiafiltration Due to Intestinal Perforation.

BACKGROUND: Disseminated intravascular coagulation (DIC) is associated with high mortality in patients with severe sepsis. The purpose of this study was to investigate the effects of recombinant human thrombomodulin (rhTM) in septic patients undergoing continuous hemodiafiltration (CHDF). Furthermore, effects of rhTM in acute lung injury, the first target organ in sepsis, were investigated using a sepsis model in rats. METHODS: Clinical laboratory data, and the DIC, Sequential Organ Failure Assessment (SOFA), and Acute Physiologic and Chronic Health Evaluation (APACHE) II scores were compared between patients undergoing CHDF alone (rhTM- group; n = 23 cases) and patients undergoing CHDF treated with rhTM (rhTM+ group; n = 21 cases). Rats underwent cecal ligation and puncture (CLP) treated with or without rhTM, and acute lung injury (ALI) was analyzed. Production of TNF-α by isolated tissue macrophages (Mfs) was assessed. RESULTS: The numbers of leukocytes, and C-reactive protein and D-dimer levels were significantly suppressed, and platelet counts recovered significantly faster in the rhTM+ group compared with the rhTM- group. The DIC score was reduced in both groups. The SOFA and APACHE II scores gradually reduced in the rhTM+ group. The CHDF treatment and ICU admission periods were shortened in the rhTM+ group compared with the rhTM- group. Treatment of rhTM was an independent factor for CHDF treatment period by multivariate analyses. CLP-induced ALI was significantly improved by rhTM. Increased TNF-α production by tissue Mfs was significantly suppressed by rhTM in vivo and in vitro. CONCLUSION: Additive effects of rhTM treatment were observed in septic patients undergoing CHDF.

Optimal treatment and complications of patients with the perforated upper gastrointestinal tract.

PURPOSE: The perforation of the upper gastrointestinal tract is still associated with a high risk of complications and mortality. We aimed to evaluate the optimal treatment and post-treatment complications for this condition. METHODS: This was a retrospective, single-center study conducted between 2010 and 2019. We analyzed 50 patients with intraperitoneal free air caused by peptic ulcer (44 cases) or cancer (six cases). RESULTS: All patients initially received either conservative therapy (n = 7) or surgery (n = 43). The nonsurgically cured patients were significantly younger and had mild peritonitis and also had a shorter hospital stay. Two patients were converted to surgery due to worsening symptoms, and one of them was elderly and had a long perforation-to-treatment time. Regarding postoperative complications, patients with Grade II-V (n = 21) were significantly older and had a poorer physical status, longer perforation-to-surgery time, and higher preoperative CRP and lactate than those with Grade 0-I (n = 24). Multivariable analyses identified elevated preoperative lactate as an independent risk factor for postoperative complications. The patients with noncurative surgery for perforated advanced gastric cancer all died within 1 year after surgery. CONCLUSIONS: Consideration should be given to the nonsurgical indications in elderly and delayed treatment patients and the postoperative outcomes of patients with preoperatively elevated lactate levels.

Laparoscopic Lavage vs Primary Resection for Acute Perforated Diverticulitis: Long-term Outcomes From the Scandinavian Diverticulitis (SCANDIV) Randomized Clinical Trial.

Importance: Perforated colonic diverticulitis usually requires surgical resection, with significant morbidity. Short-term results from randomized clinical trials have indicated that laparoscopic lavage is a feasible alternative to resection. However, it appears that no long-term results are available. Objective: To compare long-term (5-year) outcomes of laparoscopic peritoneal lavage and primary resection as treatments of perforated purulent diverticulitis. Design, Setting, and Participants: This international multicenter randomized clinical trial was conducted in 21 hospitals in Sweden and Norway, which enrolled patients between February 2010 and June 2014. Long-term follow-up was conducted between March 2018 and November 2019. Patients with symptoms of left-sided acute perforated diverticulitis, indicating urgent surgical need and computed tomography-verified free air, were eligible. Those available for trial intervention (Hinchey stages

The use of hyperbaric oxygen to treat actinic rectal fistula after SpaceOAR use and radiotherapy for prostate cancer: a case report.

BACKGROUND: In definitive radiation therapy for prostate cancer, the SpaceOAR® System, a hydrogel spacer, is widely used to decrease the irradiated dose and toxicity of rectum. On the other hand, periprostatic abscesses formation and rectal perforation are known as rare adverse effects of SpaceOAR. Nevertheless, there is a lack of reports clarifying the association between aggravation of abscesses and radiation therapy, and hyperbaric oxygen therapy (HBOT) is effective for a peri-SpaceOAR abscess and rectal perforation. CASE PRESENTATION: We report a case of a 78-year-old high-risk prostate cancer patient. After SpaceOAR insertion into the correct space, he started to receive external beam radiation therapy (EBRT). He developed a fever, perineal pain and frequent urination after the completion of EBRT, and the magnetic resonance imaging (MRI) revealed a peri-SpaceOAR abscess. Scheduled brachytherapy was postponed, administration of antibiotics and opioid via intravenous drip was commenced, and transperineal drainage was performed. After the alleviation of the abscess, additional EBRT instead of brachytherapy was performed with MRI-guided radiation therapy (MRgRT). On the last day of the MRgRT, perineal pain reoccurred, and MRI and colonoscopy detected the rectal perforation. He received an intravenous antibiotics drip and HBOT, and fully recovered from the rectal perforation. CONCLUSIONS: Our report indicates that EBRT can lead to a severe rectum complication by causing inflammation for patients with a peri-SpaceOAR abscess. Furthermore, HBOT was effective for the peri-SpaceOAR abscess and rectal perforation associated with EBRT.

The Efficacy of Autologous Myoblast Sheet Transplantation to Prevent Perforation After Duodenal Endoscopic Submucosal Dissection in Porcine Model.

The recent advent of endoscopy has enabled the endoscopic submucosal dissection (ESD) of superficial nonampullary duodenal epithelial tumors. However, the substantially thin wall and presence of bile and pancreatic juice make it technically difficult to perform duodenal ESD without perforation, which leads to lethal complications. The present study evaluated the efficacy of autologous myoblast sheet transplantation for the prevention of late perforation after duodenal ESD in a porcine model. Two weeks before ESD, skeletal muscle was surgically excised from the femur of pigs, and myoblasts were isolated and seeded in temperature-responsive culture dishes to prepare sheets. Immediately after ESD, the autologous myoblast sheets were attached to the serosal surface at the ESD site with omentopexy. The pigs were divided into two groups: the autologous myoblast sheet group (n = 5), where the myoblast cell sheet was attached to the ESD ulcer part from the duodenal serous side, and the Omentum group (n = 5), where only the omentum was used. The pigs were sacrificed and analyzed macroscopically and histologically on postoperative day 3. The macroscopic examination of the abdominal cavity revealed perforation in the ESD ulcer area and leakage of bile in the Omentum group but no perforation in the Sheet group. A histopathological examination revealed that continuity of the duodenal wall at the ESD site was maintained with dense connective tissue in the Sheet group. In conclusion, autologous myoblast sheets were useful for preventing perforation after duodenal ESD.

Closure of colonic deep mural injury and perforation with endoclips

INTRODUCTION: colorectal perforations are one of the most feared complications after performing an endoscopic resection. The use of endoclips is considered for the management of these complications. OBJECTIVES: to evaluate the efficacy and safety of the use of endoclips in the management of perforations and deep mural injuries that occur after an endoscopic colorectal resection. METHODS: a prospective cohort of consecutively included patients was used with a diagnosis of perforation or deep mural injury after an endoscopic colorectal resection treated with endoclips in our institution. The rates of perforation and deep mural injury were obtained. The factors associated with an unfavorable evolution after the placement of the endoclips were analyzed. RESULTS: after 342 endoscopic mucosal resections (EMR) and 42 endoscopic submucosal dissections (ESD), there were 25 cases with perforation or deep mural injury. The deep mural injury rate was 3.22 % and 7.14 % in the case of EMR and ESD, respectively. The perforation rate was 1.46 % and 14.29 % in the case of EMR and ESD, respectively. Successful closure with endoclips was achieved in 24 cases (96 %). Only one patient presented an unfavorable evolution (10 %) after successful closure. The factors associated with an unfavorable evolution were the presence of diffuse peritoneal symptoms and a perforation size greater than or equal to 10 mm. CONCLUSION: endoscopic closure with endoclips is effective to avoid surgery in cases of deep mural injury or perforation after an endoscopic resection

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Case Report: Paralytic Ileus: A Potential Extrapulmonary Manifestation of Severe COVID-19.

The COVID-19 pandemic has recently spread worldwide, presenting primarily in the form of pneumonia or other respiratory disease. In addition, gastrointestinal manifestations have increasingly been reported as one of the extrapulmonary features of the virus. We report two cases of SARS-CoV-2 infection complicated by paralytic ileus. The first patient was a 33-year-old man who was hospitalized with severe COVID-19 pneumonia requiring ventilator support and intensive care. He developed large bowel dilatation and perforation of the mid-transverse colon, and underwent laparotomy and colonic resection. Histopathology of the resected bowel specimen showed acute inflammation, necrosis, and hemorrhage, supporting a role for COVID-19-induced micro-thrombosis leading to perforation. The second patient was a 33-year-old man who had severe COVID-19 pneumonia, renal failure, and acute pancreatitis. His hospital course was complicated with paralytic ileus, and he improved with conservative management. Both cases were observed to have elevated liver transaminases, which is consistent with other studies. Several authors have postulated that the angiotensin-converting enzyme 2 receptors, the host receptors for COVID-19, that are present on enterocytes in both the small and large bowel might mediate viral entry and resultant inflammation. This is a potential mechanism of paralytic ileus in cases of severe COVID-19 infection. Recognizing paralytic ileus as a possible complication necessitates timely diagnosis and management.

Rare aetiology of abdominal pain: contained abscess secondary to perforated jejunal diverticulitis.

A patient with a history of multiple jejunal diverticulosis (JD) presented with a non-peritonitic abdominal pain and leucocytosis. CT scan showed a thick-walled interloop collection within the left mid-abdomen with dilated bowels and mild diffuse air-fluid levels. Exploratory laparotomy revealed multiple diverticular outpouchings in the mid-jejunum, one of which was perforated, contained within the mesentery. Resection of the contained abscess and primary anastomosis were performed subsequently.