Pediatric gastric perforation beyond neonatal period: 8-year experience with 20 patients.

BACKGROUND: To describe the characteristics, treatments, and prognosis of pediatric gastric perforation patients beyond neonatal period. METHODS: Twenty pediatric patients beyond neonatal period were included in this study. Medical records were reviewed and clinical characteristics were analyzed. According to the outcomes, patients were divided into the survival group and the death group. Death time was documented, and survival patients were followed up. The degree of severity was calculated using pediatric critical illness score (PCIS). Differences between the two groups were analyzed by the Student's t-test, Mann-Whitney test and Chi-square test appropriately. RESULTS: Gastric perforation was diagnosed in 20 pediatric patients beyond neonatal period, including 6 males (30%) and 14 females (70%), with the age of 37.18 (15.90, 107.12) months, and the range was from 4.30 months to 14.17 years old. They had different manifestations, etiologies, sites of perforation and surgery procedures. Among the 20 cases, 14 (70%) survived and 6 (30%) died. Age, gender, length and number of perforation had no statistically difference between the two groups. However, PCIS, ischemia of gastrointestinal wall, and transmural necrosis of gastric wall were statistically different. For the survival group, during a follow-up period of 50 (36, 68) months, ranging from 2 months to 8 years and 7 months, one patient had a second-time perforation, another 3 patients had brain injury symptoms, and the rest 10 patients had good quality of lives. CONCLUSIONS: Gastric perforation of pediatric patients beyond neonatal period causes a mortality of 30% on this study. Spontaneous great curvature of gastric wall perforation has the highest morbidity. Low PCIS predicts for unfavorable prognosis. Most of the survival patients have satisfactory living quality after operation.

Neonatal Gastric Perforation: Case Series and Literature Review.

PURPOSE: We reported clinical findings of neonatal gastric perforation in a tertiary children's hospital. PATIENTS AND METHODS: Retrospective chart reviews were conducted for neonatal gastric perforation between 1980 and 2016. Factors including sex, gestational age, birth weight, age, main symptoms and signs, white blood cell count (WBC), surgical intervention time (time between development of main symptom and surgical intervention), surgical findings, pathologic results, clinical outcomes, and causes of death were collected. RESULTS: Sixty-eight patients were identified. In total, 76.5% were male infants, the median age was 4 days, median birth weight was 2500 g, and 42.6% were premature. Abdominal distention and vomiting were the most common symptoms, and pneumoperitoneum was the most common radiographic finding. The median surgical intervention time was 51 h (range 8-312). In total, 73.5% of perforations occurred in the great curvature, 17.6% in the lesser curvature, and 8.9% unspecified. The median perforation size was 4 cm (range 0.2-16). Associated gastrointestinal anomalies were found in 20.6% of patients, and the most common anomaly was intestinal malrotation. Of the 51 patients with pathologic results, 11 showed the presence of musculature in the perforated gastric wall, while 40 showed the absence of musculature. Of the 66 patients with known clinical outcomes, 26 (39.4%) died, 23 of who died of infection. Among those aforementioned factors, WBC has a significant impact on survival. The mortality for four arbitrary divided year groups (1980-1989, 1990-1999, 2000-2009, and 2010-2016) was 100, 50, 31.6, and 16.7%, respectively. CONCLUSIONS: The mortality of neonatal gastric perforation is constantly decreasing. Associated gastrointestinal anomalies and the presence of musculature are found in a minority of this condition.

Fatal ingestion of floating net debris by two sperm whales (Physeter macrocephalus).

In 2008 two male sperm whales (Physeter macrocephalus) stranded along the northern California coast with large amounts of fishing net scraps, rope, and other plastic debris in their stomachs. One animal had a ruptured stomach, the other was emaciated, and gastric impaction was suspected as the cause of both deaths. There were 134 different types of nets in these two animals, all made of floating material, varying in size from 10 cm(2) to about 16 m(2). The variability in size and age of the pieces suggests the material was ingested from the surface as debris rather than bitten off from active gear. These strandings demonstrate that ingestion of marine debris can be fatal to large whales, in addition to the well documented entanglements known to impact these species.

Neonatal gastric perforation: report of 15 cases and review of the literature.

BACKGROUND: Gastric perforation among neonates is a rare but frequently fatal condition of uncertain etiology. The aim of this study was to review the clinical course of neonatal gastric perforation and to evaluate possible prognostic factors. METHODS: We retrospectively analyzed the medical records of 15 patients with neonatal gastric perforation over a 19-year period. Another 97 patients described in the medical literature, for whom the gestational ages and birth weights were clearly stated, were also reviewed. RESULTS: In our series, there were three girls and 12 boys, nine of whom were full-term infants and six preterm infants. The most common initial manifestations were poor activity, abdominal distension, and respiratory distress. The overall mortality was 47% (7/15). Prematurity was the only statistically significant risk factor; 83% (5/6) of premature infants died compared with 22% (2/9) of term babies (p < 0.05). Combining our series with the patients reported in the literature, there were a total of 50 premature infants and 62 term infants. Gastric perforation occurred on postnatal days 2-7 and presented with nonspecific manifestations. The mortality was significantly higher in premature than in term infants (31/50, 62% vs. 16/62, 26%; p < 0.001). A trend towards higher mortality in infants with lower birth weights was observed (>2500 g, 28%; 1501-2500 g, 52%; 1000-1500 g, 60%; <1000 g, 100%). Infants with birth weights <2500 g had a significantly higher mortality than infants with birth weights >2500 g (32/58, 55% vs. 15/54, 28%; p<0.05). CONCLUSION: Neonatal gastric perforation is associated with high mortality, particularly in premature infants. There is also a trend towards higher mortality in lower-birth-weight infants.

Gastric rupture and necrosis in Prader-Willi syndrome.

Hyperphagia and obesity are common features in individuals with Prader-Willi syndrome (PWS). Demographic and cause-of-death data from individuals with PWS were obtained through a national support organization. Four reports of unexpected mortality due to gastric rupture and necrosis were found in 152 reported deaths, accounting for 3% of the causes of mortality. Four additional individuals were suspected to have gastric rupture. Vomiting and abdominal pain, although rare in PWS, were frequent findings in this cohort. The physician should consider an emergent evaluation for gastric rupture and necrosis in individuals with PWS who present with vomiting and abdominal pain.

Outcomes after emergency surgery for gastric perforation or severe bleeding in patients with gastric cancer.

BACKGROUND AND OBJECTIVES: Free perforation and major bleeding in patients with gastric cancer are rare but serious conditions with potentially dangerous effects. To clarify the clinicopathologic characteristics of patients with these conditions and to determine the optimum management, we reviewed 16 cases of perforation and 13 cases of major bleeding in patients with gastric cancer who required emergency surgery. METHODS: We compared the clinical and histologic features of the patients with perforation and those with bleeding. Cox's multivariate regression analysis was used to compare survival rates between patients who underwent single-step surgery or a two-step radical procedure, between patients with stage I or II and stage III or IV cancer, between patients who underwent complete (R0) and incomplete (R1 or R2) resection, and between patients with bleeding and those with perforation. RESULTS: Many of the patients had advanced disease. There were no significant differences in clinicopathologic findings or survival between patients with gastric perforation and those with major bleeding. Patients who had major bleeding tended to have larger cancers. In the univariate analysis, gastrectomy (vs. no gastrectomy), R0 (vs. R1 or R2) resection, and lower stage (vs. higher stage) were highly correlated with improved survival time. CONCLUSIONS: Overall, patients with gastric cancers who underwent emergency gastrectomy had a poor prognosis, but it was better than that of patients who could not have gastrectomy because of the prXesence of advanced cancer. However, the survival rate was excellent in patients with early-stage cancer who underwent complete (R0) resection. We recommend complete resection when possible.

Blunt injuries of the stomach.

OBJECTIVE: To evaluate the results of surgical treatment of patients with blunt injuries of the stomach. DESIGN: Retrospective study. SETTING: Two general hospitals, Greece. SUBJECTS: 10 patients operated on for blunt trauma to the stomach during a 10 year period. MAIN OUTCOME MEASURES: Hospital mortality and morbidity. RESULTS: All patients were victims of motor vehicle accidents and presented with clinical signs warranting early laparotomy. There were 6 full-thickness, and 2 partial thickness gastric injuries located in the anterior wall. All injuries could be managed with simple surgical techniques without resections. Two patients bled to death on the operating table from associated injuries. All but one of the survivors had postoperative complications with a mean (SD) duration of hospital stay of 18(8) days (range 10-30). CONCLUSIONS: Blunt gastric injury is usually diagnosed at laparotomy for associated injuries but may occasionally be suspected from specific clinical findings. In most cases the injury is on the anterior wall. Simple repair is usually sufficient and the prognosis depends on the severity of the associated injuries.

Long-term survival after gastrectomy for advanced bleeding or perforated gastric carcinoma.

OBJECTIVE: To find out whether massive bleeding or free perforation of advanced gastric carcinoma affect long term survival after gastrectomy. DESIGN: Retrospective analysis of prospectively collected data. SETTING: Teaching hospital, Hong Kong. INTERVENTIONS: Gastrectomy. MAIN OUTCOME MEASURES: Long term survival. RESULTS: Data of 50 patients with gastric carcinoma that had penetrated the serosa (pT3) and who were operated on between 1985 and 1990 were analysed. A total of 17 patients with tumour free perforation and 10 with massive bleeding underwent emergency gastrectomy, and 23 patients with comparable uncomplicated tumours had elective gastrectomy. Twelve variables that could have influenced survival including malignant perforation, bleeding, or the absence of complications were analysed using the Cox's proportional hazards model. Survival was influenced only by proliferative cell nuclear antigen (PCNA) index and not by perforation, bleeding, or the uncomplicated nature of the tumour. CONCLUSIONS: These findings suggest that perforation or bleeding from advanced gastric carcinomas do not significantly affect long term survival after gastrectomy.

Iatrogenic ruptures of the stomach after balloon tamponade. Two case reports: viscoelastic model.

Two cases of gastric rupture as a rare complication of balloon tamponade for esophageal varices are presented. In both cases, the rupture was caused by instillation of irrigation fluid without previous aspiration of stomach contents. In an experimental study, the stomachs of 11 corpses were filled with water to determine rupture pressure and volume. The mean rupture pressure was 73 +/- 13 mm Hg (9.7 +/- 1.7 kPa) and the mean rupture volume was 2,670 +/- 410 ml. A viscoelastic model was used for the representation of the relations between pressure and volume as well as pressure and time. Measured values are significant particularly for the explanation and medicolegal evaluation of iatrogenic ruptures of the stomach that occur during gastric lavage, positive pressure respiration, incorrect intubation, or forced mask respiration during resuscitation.

Neonatal gastrointestinal perforations.

Neonatal gastrointestinal perforation has been associated with mortality rates of 40% to 70%. Over the past 20 years, 81 infants (46 boys and 35 girls) were treated for a gastrointestinal perforation at this institution. Perforation occurred from birth to 50 days (average, 8.2 days). Etiologies included necrotizing enterocolitis (NEC) (68%), meconium ileus (10%), and idiopathic gastric perforation (7%). Seventy-six infants underwent surgical exploration and five infants, considered too small or too sick to withstand a laparotomy, were treated with peritoneal lavage only. There were 29 deaths, an overall mortality of 36%. Ninety percent of the death occurred in patients with NEC, while all patients with gastric perforations survived. There has not been a significant improvement in survival in recent years, partly because of an increase in the proportion of NEC-related perforations. However, there is a narrowing of the mortality gap between low birth weight and normal weight infants. As the risk inherent to laparotomy in neonates is decreasing, other factors, such as the underlying etiology or the site of perforation, play a more important prognostic role.

Spontaneous rupture of the stomach.

Spontaneous rupture of the stomach is a rare but rapidly fatal accident. In the reported case, the galloping pace of deterioration claimed the life of the patient in spite of timely institution of resuscitative measures. However, in less catastrophic forms, provided the condition is recognised by its characteristic features, it is possible to improve the prognosis by expeditious surgical correction. It behoves us to briefly review the clinical features of this condition while presenting the case report.

[Stomach perforation in the neonatal period and in children]. / Magenperforationen im Neugeborenen- und Kindesalter.

Among the upper gastrointestinal tract perforations in infants and children, the gastric perforations were predominating. With exception of peptic ulcers, localization was found mainly in the upper parts of the stomach regarding to mechanical originating factors. Mortality depends on prematurity and additional injuries as well as the basic disorders.

Neonatal gastrointestinal perforation.

During the 7-year period from 1980 to 1986, 56 neonates with gastrointestinal (GI) perforation were treated in the Hospital for Sick Children, London. The overall mortality rate was 30%. The highest mortality rate (60%) was associated with gastric perforation, which in this series occurred only in premature neonates. Colorectal perforation carried the lowest risk of mortality (17%). The mortality rate from small bowel perforation was 35%. Prematurity and low birth weight were significant factors increasing the mortality rate from neonatal intestinal perforation. The predominant cause of perforation in the small and large intestine was necrotizing enterocolitis and the most common site of perforation was the terminal ileum. Mechanical ventilation was thought to be the cause of the perforation in four of the five neonates with gastric perforation. Primary anastomosis is a definite option in neonates who are stable intraoperatively. The mortality rate and in-patient stay for neonates who had primary anastomosis were less than for those who had stomas.

Gastrointestinal perforation in infants.

We found that the mortality rate was no greater in patients with necrotizing enterocolitis complicated by perforation compared with the rate in those with other causes of perforation in similar weight classes. Iatrogenic injuries had a 50 percent mortality rate in all gestational age and birth weight categories and, therefore, great caution and surveillance are of utmost importance when using invasive monitoring and therapeutic modalities to prevent this cause of perforation. Term infants had a preponderance of mechanical causes of perforation which mainly occurred in the foregut and proximal midgut, whereas premature infants have a preponderance of asphyxial or ischemic events underlying perforations which mainly occurred in the ileocolic region and were often associated with necrotizing enterocolitis. Although neonatal intestinal perforation is a catastrophic event, the very premature infant weighing less than 1,000 g at birth is at significantly greatest risk. The discouraging 20 percent survival rate in the less than 1,000 g premature infants presents a challenge to the surgeon, since the overall survival rate was 59 percent and the term infants had a 78 percent survival rate. A substantial share of the mortality in the infants weighing less than 1,000 g at birth relates to the occurrence of intracerebral hemorrhage and bronchopulmonary dysplasia. Vigorous medical and surgical approaches can be used to salvage premature infants in all weight classes with gastrointestinal perforation.

Studies of paralytic ileus. Effects of intraperitoneal injury on motility of the canine small intestine.

This study is significant in demonstrating that the small intestine of the dog is extremely resistant to paralytic ileus. The various types of intra-abdominal irritation studied were quite severe. After a transient period of inhibition, however, in most instances motility of the small intestine returned and continued until near the time of death. Various types of intra-abdominal irritation were used to study paralytic ileus in dogs, including intraperitoneal injection of gastric juice, gastroperitoneal fistula, appendiceal ligation, intraperitoneal injection of Lugol's iodine solution, retroperitoneal injection of blood, and mechanical and thermal irritation of the intestine and peritoneum. The electrical and mechanical activity of the small intestine was observed by means of a Thomas cannula implanted in the jejunum. The presence or absence of fluid accumulation within the intestinal lumen or peritoneal cavity was noted at autopsy. Intra-abdominal chemical irritation caused a transient inhibition of intestinal motility, which was reversed when the irritation was stopped. Repeated irritation did not appear to cause progressive, irreversible inhibition of intestinal motility. When intestinal motility was depressed, spike potentials were absent in the recordings of electrical activity of the intestine. The "slow" electrical waves were distinguishable at all times. With the exception of the gastroperitoneal fistulas, the procedures were tolerated with only transient inhibition of intestinal motility. Accumulation of intraperitoneal fluid occurred in dogs subjected to gastroperitoneal fistulas. A small amount of intraluminal fluid accumulated in dogs subjected to repeated thermal and mechanical irritation of the intestines and peritoneum. In the other groups of dogs no significant increase in intestinal or intraperitoneal fluid was observed.