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BACKGROUND: The management of type II endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is still controversial. This study aimed to compare the effects of covered self-expandable metallic stent (SEMS), surgery, and conservative treatment for type II perforation.
METHODS: From January 2010 to December 2021, this study collected relevant data from five large hospitals in China. The data of ERCP difficulty grading and ERCP-related perforation in 26,673 cases that underwent ERCP during 11 years were retrospectively analyzed. Of 55 patients with type II perforation, 41 patients were implanted with a biliary covered SEMS (stent group), 10 underwent surgery (surgery group), and 4 received conservative treatment (conservative group).
RESULTS: Among the 55 patients with type II perforation, ERCP and computed tomography diagnostic rates of type II perforation were 10.91% (6/55) and 89.09% (49/55), respectively. The incidence of type II perforation in grade 5 ERCP (0.43%, 11/2,537) was significantly higher than that in grade 1-3 ERCP (0.16%, 32/19,471). (P = 0.004) and grade 1-4 ERCP (0.26%,12/4,665) (P = 0.008), respectively. Among the 10 patients in the surgical group, primary repair was performed in only 7 patients in whom location of the perforation could be identified. The incidence of retroperitoneal abscess was significantly lower in the stent group than in the surgery group (P = 0.018) and the conservative group (P = 0.001), respectively. The average hospital stay in the stent group was shorter than that in the surgery group (P = 0.000) and conservative group (P = 0.001), respectively.
CONCLUSIONS: The incidence of type II perforation was dependent on the degree of difficulty of ERCP. The treatment of type II perforation with a covered SEMS can significantly reduce the incidence of retroperitoneal abscess and shorten the hospital stay, with better results than surgical and conservative treatments.

OBJECTIVE: To evaluate the anatomic and functional outcomes of type1 tympanoplasty with endoscopic modified butterfly cartilage-perichondrium technique.
METHODS: In our modification, perichondrium was elevated circumferentially till the attached part of the composite graft was approximately same size and shape of the perforation, cartilage was trimmed based on the perforation but 0.5 mm larger. Cartilage portion of the graft was placed medial to the edge of the perforation, then perichondrium was rolled out and draped on the circumferential raw surface of remaining tympanic membrane around.
RESULTS: At 4 months postop, the anatomic integrity rate of the tympanic membrane perforation for small & medium sized perforation and large sized perforation group were 100 % and 94 % (p > 0.05). For the small & medium perforation group, the mean pre and 4 months postop ACs were 30 ± 8 dB and 18 ± 6.4 dB (p < 0.01). The mean pre and 4 months postop ABGs were 19 ± 11 dB and 9 ± 3 dB (p < 0.01). For the large perforation group, the mean pre and 4 months postop ACs were 43 ± 12.5 dB and 21.5 ± 7 dB (p < 0.01). The mean pre and 4 months postop ABGs were 34 ± 8.5 dB and 12.5 ± 6 dB (p < 0.01). The differences of mean 4 months postop ACs and mean 4 months postop ABGs between the two groups were not significant (p > 0.05).
CONCLUSIONS: Compared to the conventional inlay butterfly cartilage tympanoplasty technique, large or marginal perforations can be sealed more securely by this modification.

BACKGROUND: Matrix metalloproteinase-7 (MMP-7) is associated with biliary injury. This study aimed to evaluate the relationships of serum MMP-7 with clinical characteristics in choledochal cysts (CDC) children.
METHODS: Between June 2020 and July 2022, we conducted a prospective study of CDCs who underwent one-stage definitive operation at our center. Serum MMP-7 was measured using an enzyme-linked immunosorbent assay. We evaluated the relationships between serum MMP-7 and age, laboratory tests, imaging examinations, liver fibrosis, MMP-7 expression, and perforation.
RESULTS: A total of 328 CDCs were enrolled in the study, with a median serum MMP-7 of 7.67 ng/mL. Higher serum MMP-7 was correlated with younger age at diagnosis (p < 0.001), larger cyst sizes (p < 0.001), higher liver fibrosis stages (p < 0.001), and higher incidence of perforation (p < 0.01). Liver MMP-7 was mainly expressed in intrahepatic and extrahepatic biliary epithelial cells. The area under the receiver operating characteristic curve (AUROC) was 0.630 (p < 0.001) for serum MMP-7 in predicting perforation. When serum MMP-7 was combined with γ-glutamyl transferase (GGT), the AUROC increased to 0.706 (p < 0.001).
CONCLUSIONS: Serum MMP-7 was associated with biliary obstruction in CDCs. Patients with high serum MMP-7 were more likely to have severe liver damage and biliary injury, with higher incidences of liver fibrosis and perforation.

BACKGROUND: To compare the clinical outcomes in patients with acute perforated peptic ulcer (PPU) treated with over-the-scope clip (OTSC), non-surgical, and surgical interventions, and to explore the effectiveness and safety of OTSC closure.
METHODS: Hospital stay, antibiotic use, diet resumption time, and mortality rate were analyzed retrospectively. Binary Logistic regression analysis was used to identify the risk factors influencing PPU complicated with sepsis.
RESULTS: Patients were divided into three treatment groups: OTSC (n = 62), non-surgical (n = 72), and surgical (n = 55) groups. The median time (IQR) from symptom onset to admission was 9.0 (4-23) h. 88.71% (55/62) of the patients in In the OTSC group underwent OTSC closure within 24 h (median [IQR] time: 14.5 [7.00-30.25] h). The perforation diameters in the OTSC and surgical groups were 9.87 mm ± 5.97 mm and 8.55 mm ± 6.17 mm, respectively. The median (IQR) hospital stays in the OTSC (9.50 [7.00-12.25] days) and non-surgical group (9.00[7.00-13.00]days) were similar (p > 0.05), but shorter than that in surgical group (12.00[10.00-16.00]days), (p < 0.05). The median duration of antibiotic use was shorter in the OTSC group (7.00[3.00-10.00]) than in the non-surgical group (9.00[7.00-11.00]) and surgical group (11.00[9.00-13.00]) ( p < 0.05); and the time to resume oral feeding was shorter in the OTSC group (4.00[2.00-5.25]) than in the non-surgical group (7.00[6.13-9.00]) and surgical group (8.00[6.53-10.00]), respectively ( p < 0.05). No mortality difference among groups (p = 0.109) was found. Lower albumin level at admission, older age, and elevated creatinine levels were associated with increased sepsis risk, with OR(95%CI) of 0.826 (0.687-0.993), 1.077 (1.005-1.154), and 1.025 (1.006-1.043), respectively (all p < 0.05).
CONCLUSIONS: OTSC closure improves clinical outcomes of acute PPU patients without sepsis. Age, hypoalbuminemia, and baseline renal dysfunction increase the risk of sepsis, while mortality was associated with sepsis and multiorgan dysfunction.

Perforation of Meckel\'s diverticulum caused by heterotopic pancreas is a rare condition. Despite recent improvements in imaging studies, Meckel\"\'s diverticulitis and heterotopic pancreas are difficult to diagnose preoperatively and are often diagnosed during autopsy or laparotomy. Symptomatic patients are typically >1 year, and cases of infants displaying symptoms are rarely reported. We report a rare case of heterotopic pancreas in Meckel\'s diverticulum causing perforation in an infant. In cases of infants presenting with unexplained acute abdominal pain, there should be a high index of suspicion for congenital gastrointestinal malformations. Prompt action in the form of exploratory laparotomy or laparoscopy is crucial to prevent the escalation of complications and to definitively confirm the diagnosis.

UNASSIGNED: Endoscopic retrograde cholangiopancreatography (ERCP)-related perforation is a rare and serious adverse event. The aim of our study was to evaluate the risk factors and management of ERCP-related perforation, and to further determine the predictive factors associated with perforation outcome.
UNASSIGNED: A total of 27,018 ERCP procedures performed at the First Affiliated Hospital of Nanchang University (Nanchang, China) between January 2007 and March 2022 were included in the investigation of ERCP-related perforation. Medical records and endoscopic data were extracted to analyse the risk factors, management, and clinical outcome of ERCP-related perforation.
UNASSIGNED: Seventy-six patients (0.28%) were identified as having experienced perforation following ERCP. Advanced age, Billroth II anatomy, precut sphincterotomy, and papillary balloon dilatation were significantly associated with ERCP-related perforation. Most patients with perforation (n = 65) were recognized immediately during ERCP whereas 11 were recognized later on. The delay in recognition primarily resulted from stent migration (n = 9). In addition, 12 patients experienced poor clinical outcome including death or hospice discharge (n = 3), ICU admission for >3 days (n = 6), and prolonged hospital stay for >1 month due to perforation (n = 3). Cancer and systemic inflammatory response syndrome (SIRS) are associated with a higher risk of poor outcome.
UNASSIGNED: Advanced age, Billroth II anatomy, precut sphincterotomy, and balloon dilation increase the risk of ERCP-related perforation whereas cancer and SIRS independently predicted poor clinical outcome.

OBJECTIVE: After endoscopic full-thickness resection (EFTR), defects require a reliable and sustained closure. We present a novel, through-the-scope \"bow-tie\" (TTS-BT) closing device enabling direct defect closure without scope withdrawal. This preclinical study aimed to evaluate the feasibility and safety of this device for large defect closure after EFTR in a porcine model.
METHODS: Exposed EFTR was performed for virtual lesions > 2 cm in the stomach of twelve pigs. Subsequently, TTS-BT closing devices were used for defect closure. Conventional metal clips were used to close any remaining defects. Gastroscopy was performed for 8 weeks to examine the wound sites and the pigs were subsequently sacrificed. After sacrificing the pigs, the wound healing was histologically verified by hematoxylin-eosin (HE) staining. The primary outcome was a successful closure rate, while the secondary outcomes were complete healing rate, closure time, and incidence of adverse events.
RESULTS: The median long and short diameters of perforations were 4.0 (3.0-6.0) cm and 3.0 (2.0-4.0) cm, respectively. Defect closure using novel TTS-BT closure devices and conventional metal clips was successfully performed in all pigs. Complete healing was achieved in the defects of 12 pigs. The median closure time was 13 (9-38) minutes. No serious adverse events occurred during the 8-week follow-up.
CONCLUSIONS: The novel TTS-BT closure device is feasible and safe for closing large gastric perforations and could be a promising tool for clinical practice.

BACKGROUND: Choledochal cyst with perforation (CC with perforation) rarely occurs, early diagnosis and timely treatment plan are crucial for the treatment of CC with perforation. This study aims to forecast the occurrence of CC with perforation.
METHODS: All 1111 patients were conducted, who underwent surgery for choledochal cyst at our hospital from January 2011 to October 2022. We conducted univariate and multivariate logistic regression analysis to screen for independent predictive factors for predicting CC with perforation, upon which established a nomogram. The predictive performance of the nomogram was evaluated using receiver operating characteristic (ROC) curves, calibration plots, and decision curve analysis (DCA) curves.
RESULTS: The age of children with choledochal cyst perforation is mainly concentrated between 1 and 3 years old. Logistic regression analysis indicates that age, alanine aminotransferase, glutamyl transpeptidase, C-reactive protein, vomiting, jaundice, abdominal distension, and diarrhea are associated with predicting the occurrence of choledochal cyst perforation. ROC curves, calibration plots, and DCA curve analysis curves demonstrate that the nomogram has great discriminative ability and calibration, as well as significant clinical utility.
CONCLUSIONS: The age of CC with perforation is mainly concentrated between 1 and 3 years old. A nomogram for predicting the perforation of choledochal cyst was established.

BACKGROUND: The incidence of magnet ingestion in children has escalated concurrent with the rise in popularity of magnetic playthings, bearing the capacity to induce substantial morbidity.
OBJECTIVE: The objective of this study was to encapsulate our accumulated expertise in handling pediatric cases featuring multiple magnetic foreign bodies within the gastrointestinal tract sometimes necessitating surgical intervention, as well as to formulate a clinical management algorithm.
METHODS: This was a retrospective review of patients with multiple magnetic foreign bodies in the digestive tract, admitted to Shenzhen Children\'s Hospital, between January 2018 and December 2022.
RESULTS: A total of 100 cases were included in this study, including 66 males and 34 females. The main clinical manifestation ns were abdominal pain and vomiting. All patients had abdominal x-ray, all of which indicated foreign bodies in the digestive tract. 33 patients had to undergo a surgical intervention. Among these cases, the gastrointestinal complications occurred in 31 patients, including gastric rupture (n = 9), intestinal obstruction (n = 11) and intestinal perforation (n = 30). Postoperative intestinal obstruction occurred in 6 children. There was no statistical significant difference in age and gender between the Surgical group and Non-surgical group, but the Surgical group had a higher number of magnets ([7.5(2-44) vs 4(2-20)], p = 0.009), a longer interval between time of misingestion to clinical visit ([48(7.2-480) vs 5(2-336)]hours, p < 0.001), and a longer length of hospital stay ([10(6-19) vs 2(1-8)]days, p < 0.001).
CONCLUSIONS: Multiple magnet ingestion in children can lead to serious complications and carry severe risks. Timely diagnosis and effective treatment are crucial for managing such patients.