Prevention of Septal Perforation Using a Combination of Crushed Cartilage and Thin Silastic Sheet During Septoplasty

Background and Objectives: The aim of the present study was to investigate the effects of a combination of crushed cartilage and thin silastic sheet for patients with a risk of septal perforation during septoplasty.Materials and Methods: A total of 195 people who underwent septoplasty surgery at Dong-A University Hospital from January 2019 to December 2020 were enrolled retrospectively. Among 195 people, our surgical method was provided for those with damage to both septal mucosa. The cartilage was collected, crushed with the cartilage crusher, and inserted between perforated mucosa. After the cartilage insertion, a 0.254-mm-thin silastic sheet was designed to cover both sides of the perforated septal mucosa. Next, a penetrating suture was placed. After thin silastic was applied on both mucosa, a 1-mm-thick silastic sheet was inserted on both sides of the nasal cavity and penetrating sutures were placed on the anterior and inferior septum. The operation concluded after packing both sides of the nasal cavity using non-absorbable packing material. The packing was removed on the second day after the operation, and the nasal cavity condition was checked every week. Thick silastic sheets were removed 5 days after surgery, and thin silastic sheets were maintained until both septal mucosa healed.Results: Of nine total cases, only one 78-year-old male experienced septal perforation at the cartilage portion two months after surgery. In this case, no other action was taken to cover the perforation site because he reported no symptoms or discomfort during the 9 months after surgery. In the other eight cases, both septal mucosa healed completely, and there were no complications.Conclusion: This method with crushed cartilage and silastic sheets to fill the defect after septal surgery is thought to help prevent postoperative perforation at no additional cost, and further research is needed.

The Effect of TISSEELTM on Confined Bowel Perforation: An Experimental Study

<b><i>Objective:</i></b> During the last decades, surgeons of several specialties presenting different levels of expertise in colon handling have been involved in laparoscopic procedures. The aim of the present experimental study was to investigate the feasibility of TISSEEL^TM versus the conventional suture placement technique on confined bowel lesions in rats. <b><i>Methods:</i></b> Twenty-four Sprague-Dawley rats underwent confined bowel perforation and were divided into three groups: the SUTURE group (sutures were used), the SUTURE + TISSEEL^TM group (sutures and TISSEEL^TM were utilized), and the TISSEEL^TM group (only TISSEEL^TM was used). Blinded histopathologic analysis followed animal sacrifice. <b><i>Results:</i></b> The median weight of the rats was 526 ± 50 g. A single animal had hematochezia on the first postoperative day. Cessation of bleeding at the perforation margin was indicated intraoperatively after TISSEEL^TM application. Animals in the TISSEEL^TM group presented less intraperitoneal adhesions and lower hemorrhagic infiltration compared to animals of the two other groups. In addition, animals in the TISSEEL^TM group showed thrombus formation at the bowel perforation site compared to animals of the two other groups (<i>p</i> = 0.042). Histopathologic analysis demonstrated reduced inflammatory reaction (<i>p</i> = 0.003), diminished fibrosis (<i>p</i> = 0.001), and better tissue regeneration (<i>p</i> = 0.000) in the TISSEEL^TM group compared to the other two groups. <b><i>Conclusion:</i></b> Application of TISSEEL^TM at the perforation site was associated with increased regeneration of the intestinal wall and less inflammatory and fibrotic reaction compared to suture placement. However, more experimental and clinical studies should be conducted before implementation in humans.

Controversy of indomethacin eye drops in the treatment of rheumatoid arthritis-induced corneal ulceration: a case report

Background Perforation of the cornea is a rare finding in patients with rheumatoid arthritis (RA). Addressing a perforated cornea associated with RA is challenging, since its pathogenesis is not fully elucidated. Topical nonsteroidal anti-inflammatory drugs (NSAIDs) were developed to prevent cystoid macular edema following cataract surgery in patients at risk. Their prescription in inflammation of the anterior segment of the eye may induce negative effects on the ocular surface. We bring into focus a corneal perforation in a patient with RA who used indomethacin eye drops to treat corneal ulceration, but responded promptly to drug discontinuation and initiation of topical cyclosporine 0.1%. Our aim is to emphasize two issues: the contraindication of topical indomethacin in corneal defects, and the immediate positive impact of topical cyclosporine 0.1% on corneal healing. Case presentation A 73-year-old Caucasian woman with a 13-year history of RA was treated for corneal ulceration in her oculus sinister (OS) with topical indomethacin and gentamicin. The patient was being treated with systemic immunosuppression and NSAIDs for the underlying RA and artificial tears in both eyes. No bandage contact lens was used. After 3 weeks of treatment, perforation of the left cornea occurred and the patient was referred to our hospital. Upon admission, visual acuity (VA) in the OS was 20/630. Slit lamp examination of the OS revealed paracentral corneal perforation, iris plugging the perforation site, shallow anterior chamber, clear aqueous humor, and clear lens. Anterior segment optical coherence tomography showed the inclavated iris in the perforation site and minimum corneal thickness of 101 µm. Topical NSAIDs were discontinued and topical treatment was initiated with tobramycin, tropicamide 1%, phenylephrine 10%, and artificial tears five times a day, and occlusive patch. For 5 days, there was no improvement, so topical cyclosporine 0.1% was started, one drop every evening. Within 7 days, the cornea had healed, the iris was liberated from the perforation site, the minimum corneal thickness increased to 250 µm, VA improved to 20/25, and the patient was free of symptoms. Conclusions The main “takeaway” lessons from this case are that topical indomethacin should not be prescribed in cases of inflammation of the anterior segment of the eye, and that topical cyclosporine was efficacious in healing corneal perforation in our patient.

Endoscopic Closure of an Acute Duodenal Perforation Occurring during Endoscopic Ultrasound Using Endoclips and Polyglycolic Acid Sheets with Fibrin Glue

Acute duodenal perforation during endoscopic ultrasound (EUS) is a serious complication. The conventional endoscopic treatment for duodenal perforations such as endoscopic clipping is unsatisfactory; recently, the effectiveness of over-the-scope clipping (OTSC) has been reported. A 91-year-old woman was referred to our hospital with the chief complaint of jaundice. Contrast-enhanced computed tomography showed a 2-cm mass in the pancreatic head; we planned EUS-guided fine-needle aspiration. During exploration for a puncture route from the duodenal bulb using a linear echoendoscope under carbon dioxide insufflation, the duodenal lumen was suddenly filled with blood. A perforation <15 mm was identified in the superior duodenal horn. We attempted an endoscopic closure with multiple endoclips but could not completely close the perforation site. Strips of bioabsorbable polyglycolic acid (PGA) sheets were placed over the gaps between the endoclips with biopsy forceps and fixed in place with fibrin glue, completely covering the perforation site. Two days after the procedure, the perforation site had closed. Nine days later, endoscopic biliary stenting was performed. The patient was diagnosed with pancreatic cancer through bile cytology, and the optimal supportive care for her age was selected. Endoscopic tissue shielding with PGA sheets and fibrin glue is increasingly being reported for use during gastrointestinal endoscopic procedures. In this case, surgery was avoided due to successful endoscopic treatment using endoclips and PGA sheets with fibrin glue without OTSC. This method may be useful for repairing acute duodenal perforations during EUS and should therefore be known to pancreatobiliary endoscopists.

Suitable Diagnosis and Treatment of Esophageal Ruptures in Cases of Non-Boerhaave Syndrome: A Comparison With Boerhaave Syndrome

Boerhaave syndrome (BS) is frequently reported in cases of esophageal perforation; however, there are relatively few studies on non–Boerhaave syndrome (nBS). This study clarifies the appropriate diagnosis and treatment for patients with nBS among those with esophageal ruptures. Twelve patients with esophageal ruptures who underwent surgery at our department over 14 years were classified into 2 groups: 4 in the nBS group and 8 in the BS group. Patient characteristics, surgical methods, surgical outcomes, and complications were compared between the groups. The chief complaints varied between the groups. The nBS group had significantly higher preoperative C-reactive protein ( P = .007) and required 5 days (median) from onset to surgery. Moreover, the perforation diameter was significantly smaller in the nBS group than in the BS group ( P = .013). Suturing of the perforation site was performed during the initial surgery in 8 BS group patients (100%) and 1 nBS group patient (25%; P = .018). Only drainage was performed during the initial surgery for 3 nBS group patients (75%). The complications did not significantly differ between the groups ( P = 1.000), and no deaths were reported. The chief complaints of patients with nBS are diverse, and esophageal perforation should be cited as a differential diagnosis even in the absence of vomiting or chest pain symptoms. In the initial surgery for patients with nBS, the perforation site does not necessarily need to be closed. It is treatable by second-stage surgery or by natural closing.

P164 Esophageal perforations. Fighting between time, severity and individualization: a collective interhospital Upper GI Unit experience.

Aim Esophageal perforation is a serious injury associated with high morbidity and mortality. The management ranges from observation to operative treatment. The aim of this study was to evaluate safety and efficacy of different treatment strategies in patients with esophageal perforation depending on the severity and time from diagnosis to treatment. Background & Methods We performed a retrospective review of a prospective esophageal perforation database from two Upper GI Units between 01/01/2014 and 31/12/2018. Patients admitted for esophageal perforation were identified and reason of perforation, perforation site, time of diagnosis, management, length of stay (LOS) and outcomes were recorded. Results Sixteen patients were identified. Reason of perforation was Boerhaave's syndrome in n=9 (56.2%), iatrogenic in n=4 (25%) and foreign body in n=2 (12.5%) patients. Perforation site was distal esophagus in n=11 (68.7%) mid- esophagus in n=3 (18.7%) and Upper esophagus in n=2 (12.5%) patients. Time from perforation to diagnosis was 24h in n=12 (75%) and 48h in n=4 (25%) patients. Treatment in patients diagnosed the first 24h was esophagectomy in n=5 (41.6%), primary closure in n=2 (16.6%) and feeding tube along with thoracotomy and washout in n=2 (16.6%). Conservative management was offered in n=2 (16.6%). Patients diagnosed after 24h were managed with chest drains (50%) and stent insertion (50%). Mean LOS in patients that required surgical intervention was 18.2 days (Range: 6-60), while mean LOS in those who did not required was 11.1 days (Range: 1-37) Eleven (68.7%) patients were discharged in good clinical condition. Consclusion Esophageal perforations should be treated in specialized Upper GI Units due to the severity of the injury. Treatment plan should be individualized.