Novel treatment options for perforations of the upper gastrointestinal tract:Endoscopic vacuum therapy and over-the-scope clips

Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention.In the past years,covered selfexpanding metal stents were the mainstay of endoscopic therapy.However,two new techniques are now available that enlarge the possibilities of defect closure:endoscopic vacuum therapy(EVT),and over-the-scope clip(OTSC).EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage.Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing,comparable to the application of vacuum therapy in cutaneous wounds.The system is changed every 3-5 d.The overall success rate of EVT in the literature ranges from 84%to 100%,with a mean of 90%;only few complications have been reported.OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope.By bringing the edges of the perforation into the cap,by suction or by dedicated devices,such as anchor or twin grasper,the OTSC can be placed to close the perforation.For acute endoscopy associated perforations,the mean success rate is 90%(range:70%-100%).For other types of perforations(postoperative,other chronic leaks and fistulas)success rates are somewhat lower(68%,and59%,respectively).Only few complications have been reported.Although first reports are promising,further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.

Role of over the scope clips in the management of iatrogenic gastrointestinal perforations

Advances in endoscopic and surgical techniques have increased the frequency and complexity of these procedures and associated complications such as gastrointestinal perforation. With the advancements in the field of gastroenterology, the promising use of an over the scope clips(OTSC) has fulfilled the unmet need for a reliable endoscopic devise in approximation of gastrointestinal perforation. This novel approach has raised the level of confidence in endoscopist in dealing with this serious complication during endoscopy. Here we have shared our experience with OTSC to evaluate its efficacy and safety in managing iatrogenic gastrointestinal perforations during endoscopy.

Multiple endocrine neoplasia type 1 with upper gastrointestinal hemorrhage and perforation:A case report and review

Multiple endocrine neoplasia type 1(MEN1) is a rare hereditary syndrome known to predispose subjects to endocrine neoplasms in a variety of tissues such as the parathyroid glands,pituitary gland,pancreas and gastrointestinal tract.We herein report a patient with a past history of pituitary adenoma,presenting with symptoms of chronic diarrhea for nearly one year and a sudden upper gastrointestinal hemorrhage as well as perforation without signs.Nodules in the duodenum and in the uncinate process and tail of pancreas and enlargement of the parathyroid glands were detected on preoperative imaging.Gastroscopy revealed significant ulceration and esophageal reflux diseases.The patient underwent subtotal parathyroidectomy and autotransplantation,pylorus-preserving pancreaticoduodenectomy and pancreatic tail resection and recovered well.The results observed in our patient suggest that perforation and bleeding of intestine might be symptoms of ZollingerEllison Syndrome in patients with MEN1.

Procalcitionin as a diagnostic marker to distinguish upper and lower gastrointestinal perforation

AIM To assess the accuracy of serum procalcitionin(PCT)as a diagnostic marker in verifying upper and lower gastrointestinal perforation(GIP).METHODS This retrospective study included 46 patients from the surgical intensive care unit(ICU)of the Second Affiliated Hospital of Harbin Medical University who were confirmed to have GIP between June 2013 and December 2016.Demographic and clinical patient data were recorded on admission to ICU.Patients were divided into upper(n=19)and lower(n=27)GIP groups according to the perforation site(above or below Treitz ligament).PCT and WBC count was obtained before laparotomy and then compared between groups.Meanwhile,the diagnostic accuracy of PCT was analyzed.RESULTS Patients with lower GIP exhibited significantly higher APACHE II score,SOFA score and serum PCT level than patients with upper GIP(P=0.017,0.004,and0.001,respectively).There was a significant positive correlation between serum PCT level and APACHE II score or SOFA score(r=0.715 and r=0.611,respectively),while there was a significant negative correlation between serum PCT level and prognosis(r=-0.414).WBC count was not significantly different between the two groups,and WBC count showed no significant correlation with serum PCT level,APACHE II score,SOFA score or prognosis.The area under the receiver operating characteristic curve of PCT level to distinguish upper or lower GIP was 0.778.Patients with a serum PCT level above 17.94 ng/d L had a high likelihood of lower GIP,with a sensitivity of 100%and a specificity of 42.1%.CONCLUSION Serum PCT level is a reliable and accurate diagnostic marker in identifying upper or lower GIP before laparotomy.

Subcutaneous cervical emphysema and pneumomediastinum due to a lower gastrointestinal tract perforation

This case report describes a 69-year-old man presen-ting with an extensive subcutaneous emphysema in his neck and generalized peritonitis caused by a lower gastrointestinal tract perforation. This case emphasizes that subcutaneous emphysema patients with negative thoracic findings should be scrutinized for signs of retroperitoneal hollow viscus perforation.

New devices and techniques for endoscopic closure of gastrointestinal perforations

Gastrointestinal perforations,which need to be managed quickly,are associated with high morbidity and mortality. Treatments used to close these perforations range from surgery to endoscopic therapy. Nowadays,with the development of new devices and techniques,endoscopic therapy is becoming more popular. However,there are different indications and clinical efficacies between different methods,because of the diverse properties of endoscopic devices and techniques. Successful management also depends on other factors,such as the precise location of the perforation,its size and the length of time between the occurrence and diagnosis. In this study,we performed a comprehensive review of various devices and intro-duced the different techniques that are considered effective to treat gastrointestinal perforations. In addition,we focused on the different methods used to achieve successful closure,based on the literature and our clinical experiences.

Unusual complication in patient with Gardner's syndrome: Coexistence of triple gastrointestinal perforation and lower gastrointestinal bleeding: A case report and review of literature

Gardner's syndrome(GS) is a rare syndrome with autosomal dominant inheritance, which is characterized by multiple intestinal polyps, dental anomalies, desmoid tumors, and soft tissue tumors. All gastrointestinal symptoms seen in GS are associated with the underlying familial adenomatosis polyposis and abdominal desmoid tumors, with the most common symptoms being anemia, lower gastrointestinal bleeding, abdominal pain, diarrhea, obstruction, and mucous defecation. To our best knowledge, no case of GS that has presented with gastrointestinal perforation and bleeding has ever been reported in the English language medical literature. A 37-year-old male who had been diagnosed with GS five years earlier was referred to our clinic for lower gastrointestinal bleeding. Despite the absence of a bleeding focus on conventional angiography, the patient was operated on with laparotomy, due to the persistence of both signs and symptoms of mild peritonitis. On the laparotomy, the patient was noted to have areas of perforation in the duodenum, splenic flexura, and midrectum. The third and fourth part of the duodenum, the proximal 15 cm segment of the jejunum, a 10 cm segment of the terminal ileum, the whole colon, and the upper and middle rectum were resected, and duodenojejunal side-to-side anastomosis and terminal ileostomy were performed. The histopathological analysis of the large mass measuring 30 cm × 20 cm was reported as a desmoid tumor. The pathological examination of the tumor foci detected in the colonic specimen revealed poorly differentiated adenosquamous carcinoma.

Perforation of the colon by invading recurrent gastrointestinal stromal tumors during sunitinib treatment

The molecular targets of sunitinib are receptor tyrosine kinases (RTKs),and this drug has also been known to exert blocking effects on the activation of KIT,which is similar to the mechanism of action of imatinib. Moreover,sunitinib has an additional anti-angiogenic effect through its inhibition of the vascular endothelial growth factor receptor activation. We report here a 70-year-old patient diagnosed with a recurrent gastrointestinal stromal tumor (GIST),which invaded the transverse colon and led to a perforation during sunitinib treatment. A computed tomography scan and 3-dimensional reconstruction showed necrosis of the recurrent hepatic mass and perforation of the invaded transverse colon. After percutaneous drainage of the intraperitoneal abscess,antibiotic treatment and restricted diet,the condition of the patient improved. The present case is the first to report that sunitinib,which is administered to treat GIST resistant to imatinib,can cause unexpected colon perforation and subsequent peritonitis.

Risk factors for postoperative sepsis in patients with gastrointestinal perforation

BACKGROUND Sepsis is fatal in patients with gastrointestinal perforation(GIP).However,few studies have focused on this issue.AIM To investigate the risk factors for postoperative sepsis in patients with GIP.METHODS This was a retrospective study performed at the Department of General Surgery in our treatment center.From January 2016 to December 2018,the medical records of patients with GIP who underwent emergency surgery were reviewed.Patients younger than 17 years or who did not undergo surgical treatment were excluded.The patients were divided into the postoperative sepsis group and the non-postoperative sepsis group.Clinical data for both groups were collected and compared,and the risk factors for postoperative sepsis were investigated.The institutional ethical committee of our hospital approved the study.RESULTS Two hundred twenty-six patients were admitted to our department with GIP.Fourteen patients were excluded:Four were under 17 years old,and 10 did not undergo emergency surgery due to high surgical risk and/or disagreement with the patients and their family members.Two hundred twelve patients were finally enrolled in the study;161 were men,and 51 were women.The average age was 62.98±15.65 years.Postoperative sepsis occurred in 48 cases.The prevalence of postoperative sepsis was 22.6%[95%confidence interval(CI):17.0%-28.3%].Twenty-eight patients(13.21%)died after emergency surgery.Multiple logistic regression analysis confirmed that the time interval from abdominal pain to emergency surgery[odds ratio(OR)=1.021,95%CI:1.005-1.038,P=0.006],colonic perforation(OR=2.761,CI:1.821–14.776,P=0.007),perforation diameter(OR=1.062,95%CI:1.007-1.121,P=0.027),and incidence of malignant tumorrelated perforation(OR=5.384,95%CI:1.762-32.844,P=0.021)were associated with postoperative sepsis.CONCLUSION The time interval from abdominal pain to surgery,colonic perforation,diameter of perforation,and the incidence of malignant tumor-related perforation were risk factors for postoperative sepsis in patients with GIP.

Gastrointestinal perforation due to incarcerated Meckel's diverticulum in right femoral canal

Meckel's diverticulum is a very common congenital anomaly of the gastrointestinal tract but many cases remain asymptomatic and are diagnosed incidentally during laparoscopic or other surgical procedures. Cases of femoral hernia involving Meckel's diverticulum are rare, with less than 50 cases reported in the literature since Littre published the first description of this coincident condition over 300 years ago. While all true "Littre's hernias" contain a Meckel's diverticulum, the involved anatomical sites are various, the most common being the inner groin(inguinal), the outer groin(femoral), and the belly button(umbilical). Complications of Littre's hernias include incarceration, strangulation, necrosis, and perforation. Herein, we describe a case of Littre's hernia that involved an incarcerated Meckel's diverticulum in a femoral hernia that was diagnosed upon investigation of symptomology manifesting from perforation and was successfully managed by surgical resection with stapler devices.

Perforation of metastatic melanoma to the small bowel with simultaneous gastrointestinal stromal tumor

The gastrointestinal tract (GIT) is a common site of metastases for malignant melanoma. These metastatic tumors are often asymptomatic. We describe a case of a 58-year-old male who presented with a sudden onset of generalized abdominal pain. The patient's past medical history was significant for lentigo melanoma of the right cheek. Laparotomy was performed and two segments ofsmall bowel, one with a perforated tumor, the other with a non-perforated tumor, were removed. Histology and immunohistochemical staining revealed the perforated tumor to be a metastatic malignant melanoma and the non-perforated tumor was found to be a gastrointestinal stromal tumor (GIST). The patient was discharged 7 d postoperatively. To the best of our knowledge, this is the first reported case in the literature of a simultaneous metastatic malignant melanoma and a GIST. Surgical intervention is warranted in patients with symptomatic GIT metastases to improve the quality of life or in those patients with surgical emergencies.

Diagnosis of upper gastrointestinal perforation complicated with fistula formation and subphrenic abscess by contrast-enhanced ultrasound:A case report

BACKGROUND Gastrointestinal perforation complicated by subphrenic abscess is a surgical emergency.Its diagnosis relies mainly on X-ray or computed tomography(CT),while the value of ultrasound,especially contrast-enhanced ultrasound(CEUS),has been underestimated.CASE SUMMARY A 37-year-old man presented with fever and edema of the lower extremities for 10 d.He had a history of laparoscopic repair of gastroduodenal perforation 6 mo prior.His first-time intravenous CEUS indicated a diagnosis of subphrenic abscess.He received antibiotic therapy and ultrasound-guided percutaneous drainage of the abscess.However,second-time intravenous CEUS revealed an unsatisfactory therapeutic effect.Intracavitary CEUS was proposed,and this examination detected communication between the abscess and the stomach.Upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess was diagnosed with the help of CEUS.Abdominal CT and esophagogastroduodenoscopy confirmed the diagnosis.The patient recovered after the perforation was repaired by surgery.CONCLUSION Intravenous and intracavitary CEUS provides helpful information for the diagnosis of upper gastrointestinal perforation complicated by fistula formation and subphrenic abscess.

Endoscopic management of iatrogenic gastrointestinal perforations

Iatrogenic perforation(IP)is a rare but severe complication of endoscopy,and occurrences grow with the expansion of interventional endoscopy.Apart from symptoms and physical signs,CT scans provide an immediate and comprehensive diagnosis of IP and its severity.The general treatment is broad-spectrum antibiotics,intravenous nutrition,and close monitoring.Endoscopic treatments are considered as the first-line therapy.Endoclips are usually utilized for small perforations,while endoclips with endoloops and over the scope clip system are preferred for large ones.Covered self-expandable metal stents are effective for esophageal perforations.Fibrin glue and band ligation can be attempted,when the location of perforation is difficult for the clip placement.Close observation is required after the procedure.If endoscopic closure fails or deterioration occurs,surgical treatments should be requested.

Perinatal risk factors in newborns with gastrointestinal perforation

AIMTo investigate correlation of perinatal risk factors in newborns with gastrointestinal perforation (GIP).METHODSSingle-center retrospective cohort study was conducted between January 1990 and December 2012. Medical records on all newborns with GIP were reviewed (n = 35). Surgical records and histopathologic examination of all perforated intestine samples were also reviewed.RESULTSThe most common cause of GIP was necrotizing enterocolitis (51.4%). The most common site of perforation was large intestine. Mortality rate was 31%. Infants with GIP more frequently had very low birth weight (< 1500 g), especially birth weight below 10th percentile according to gestational age. Ponderal index was not differing between infants with GIP and control subjects. In infants with GIP anemia was more frequently found than in control group.CONCLUSIONGIP in newborns is mostly disease of infants with birth weight below 10th percentile according to gestational age. GIP occurs more often in infants with anemia.

Therapeutic effect of Western Medicine plus Traditional Chinese Medicine in the treatment of upper gastrointestinal tract perforation

OBJECTIVE: To explore the clinical efficacy of Traditional Chinese Medicine(TCM) combined with Western Medicine in the treatment of upper gastrointestinal tract perforation.METHODS: Totally 100 patients with upper gastrointestinal tract perforation hospitalized between January 2010 and January2015 were included and randomly divided into the control group and the observation group, 50 patients in each group. The patients in the control group received the conventional nonsurgical treatment of Western Medicine, whereas those in the observation group were treated by TCM plus the treatment given to the control group. The first period was defined as the closed perforation period, during which electro-acupuncture was performed at acupoints of Zusanli(ST36) and Zhongwan(Ren 12); the second period as the absorption period, during which Dachengqi Decoction was administered to restore normal bowel movement; the third period as the ulcer healing period,during which the TCM treatment was admini-stered based on the formula of Pingweisan. Patients in both groups were reexamined by endoscopy after 2 weeks of treatment.RESULTS: The time to relieve abdominal pain, the time to pass gas and the length of stay in the observation group were significantly improved compared with those in the control group(P<0.05). The cure rate of the observation group was significantly higher than that of the control group(P<0.05).After two weeks of treatment, in the observation group, the cured patients showed closed perforation, with disappearing mucosal congestion and edema, less white fur on the ulcers and shallower ulcers in the size of 3 to 5 mm; the ulcer was in the healing period and none of the patients showed acute perforation again. While in the control group, two patients were given endoscopy after 10 days of treatment, after which ulcer and acute perforation recurred.CONCLUSIONS: The treatment of upper gastrointestinal tract perforation by Western Medicine and TCM in combination could, at different stages, significantly shorten the time to relieve abdominal pain, the time to pass gas, and the length of stay, thus improving the cure rate.

Effects of dexmedetomidine and sufentanil on hemorheology,stress response and inflammatory factors in patients undergoing laparoscopic repair of gastrointestinal perforation

Objective: To observe the clinical application of dexmedetomidine combined with sufentanil anesthesia in patients undergoing laparoscopic repair of gastrointestinal perforation, and the changes of hemodynamics, stress response and inflammatory factors were analyzed before and after operation. Methods: A total of 102 patients with laparoscopic gastrointestinal perforation were randomly divided into control group (n=51) and observation group (n=51) according to the lottery method. The control group was given anesthesia with sufentanil, and the observation group was given dexmedetomidine combined with sufentanil anesthesia, and the other anesthesia drugs were the same. The hemodynamics before anesthesia induction (T1), 10 min after medication (T2), pneumoperitoneum (T3), and tube drawing (T4), serum stress response and inflammatory factor levels before operation and after 24 h of operation were measured in all subjects. Results: At T1 and T2, there was no significant difference in hemodynamics between the two groups. At T3and T4, HR, SBP, and DBP in observation group were significantly lower than those in the control group at corresponding period, and compared with the observation group at T, there were no significant difference. At T3, and T4, the HR, SBP and DBP of the control group were significantly higher than those of T1. There was no significant difference in serum stress hormone between the two groups before surgery. After surgery 24 h, two groups of serum ACTH, Cor and ALD levels were higher than those of preoperative, and the observation group was significantly lower than those of the control group. There was no significant difference in serum inflammatory cytokines between the two groups before surgery. After surgery 24 h, the levels of serum IL-10 and TNF-毩 in the two groups were higher than those before operation, and the observation group was significantly lower than those of the control group. Conclusion: The combination of dexmedetomidine and sufentanil anesthesia can maintain hemodynamic stability of patients reduce the stress response and serum inflammatory factor concentration, which is one of the potential effective anesthesia method.

A Rare Cause of Pneumoperitoneum: Perforated Gastrointestinal Stromal Tumor (GIST)

Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor and has a malignant potential. The clinical presentation with pneumoperitoneum and peritonitis is extremely rare. We report a case of a 40-year-old male presented with symptoms of acute abdomen. Radiological work-up confirmed pneumoperitoneum. Emergency laparatomy and complete resection were performed. The final diagnosis revealed perforated GIST originating from the jejunum. If an abdominal mass presents with pneumoperitoneum and peritonitis, jejunal GIST should be considered in diagnosis. A complete radical resection followed by postoperative adjuvant chemotheraphy with Imatinib is recommended.

One hundred and one over-the-scope-clip applications forsevere gastrointestinal bleeding,leaks and fistulas

AIM: To investigate the efficacy and clinical outcome of patients treated with an over-the-scope-clip(OTSC) system for severe gastrointestinal hemorrhage, perforations and fistulas.METHODS: From 02-2009 to 10-2012, 84 patients were treated with 101 OTSC clips. 41 patients(48.8%) presented with severe upper-gastrointestinal(GI) bleeding, 3(3.6%) patients with lower-GI bleeding, 7 patients(8.3%) underwent perforation closure, 18 patients(21.4%) had prevention of secondary perforation, 12 patients(14.3%) had control of secondary bleeding after endoscopic mucosal resection or endoscopic submucosal dissection(ESD) and 3 patients(3.6%) had an intervention on a chronic fistula. RESULTS: In 78/84 patients(92.8%), primary treatment with the OTSC was technically successful. Clinical primary success was achieved in 75/84 patients(89.28%). The overall mortality in the study patients was 11/84(13.1%) and was seen in patients with life threatning upper GI hemorrhage. There was no mortality in any other treatment group. In detail OTSC application lead to a clinical success in 35/41(85.36%) patients with upper GI bleeding and in 3/3 patients with lower GI bleeding. Technical success of perforation closure was 100% while clinical success was seen in 4/7 cases(57.14%) due to attendant circumstances unrelated to the OTSC. Technical and clinic success was achieved in 18/18(100%) patients for the prevention of bleeding or perforation after endoscopic mucosal resection and ESD and in 3/3 cases of fistula closure. Two application-related complications were seen(2%).CONCLUSION: This largest single center experience published so far confirms the value of the OTSC for GI emergencies and complications. Further clinical experience will help to identify optimal indications for its targeted and prophylactic use.

Colon perforation due to antigenemia-negative cytomegalovirus gastroenteritis after liver transplantation: A case report and review of literature

BACKGROUND Cytomegalovirus(CMV) remains a critical complication after solid-organ transplantation. The CMV antigenemia(AG) test is useful for monitoring CMV infection. Although the AG-positivity rate in CMV gastroenteritis is known to be low at onset, almost all cases become positive during the disease course. We treated a patient with transverse colon perforation due to AG-negative CMV gastroenteritis, following a living donor liver transplantation(LDLT).CASE SUMMARY The patient was a 52-year-old woman with decompensated liver cirrhosis as a result of autoimmune hepatitis who underwent a blood-type compatible LDLT with her second son as the donor. On day 20 after surgery, upper and lower gastrointestinal endoscopy(GE) revealed multiple gastric ulcers and transverse colon ulcers. The biopsy tissue immunostaining confirmed a diagnosis of CMV gastroenteritis. On day 28 after surgery, an abdominal computed tomography revealed transverse colon perforation, and simple lavage and drainage were performed along with an urgent ileostomy. Although the repeated remission and aggravation of CMV gastroenteritis and acute cellular rejection made the control of immunosuppression difficult, the upper GE eventually revealed an improvement in the gastric ulcers, and the biopsy samples were negative for CMV. The CMV-AG test remained negative, therefore, we had to evaluate the status of the CMV infection on the basis of the clinical symptoms and GE.CONCLUSION This case report suggests a monitoring method that could be useful for AGnegative CMV gastroenteritis after a solid-organ transplantation.