A 62-year-old man visited our hospital emergency room with dizziness and diaphoresis. He received an acupuncture treatment on the subxyphoid area (lower 2 cm and left 1 cm point from the lower xyphoid process border) directly an hour ago because of facial numbness. He had a history of cerebral infarction and permanent atrial fibrillation on warfarinization (2 mg warfarin per day). Surprisingly, the acupuncture needle () was still sticking into his substernum. The initial vital signs were blood pressure of 80/50 mm Hg and heart rate of 110 beats/min. We instantly removed the needle, but he went into cardiac arrest and was rescued within 10 minutes after cardiopulmonary resuscitation. At that time his prothrombin time international normalized ratio was 1.99, therefore, we administered 2 pints of fresh frozen plasma and 5 mg of vitamin K. The transthoracic echocardiography revealed pericardial effusion with early diastolic collapse of the right ventricle. We performed emergent pericardiocentesis using a subcostal approach. After drainage of 500 mL of sanguineous effusion, the patient stabilized hemodynamically. Two hours later, however, the drainage of pericardial effusion persisted up to the total amount of 1000 mL, and the cardiac arrest redeveloped. After resuscitation, an emergent operation was performed under cardiopulmonary bypass (CPB). A median sternotomy allowed visualization of huge hematomas over right atrium and ventricle (). After we evacuated the hematomas, a pumping of acute marginal branch of the right coronary artery was identified. The vessel was torn into pieces, and it was ligated with 4-0 Prolene suture, thereby leading to termination of bleeding (). The aortic cross clamp time was 25 minutes and CPB time was 45 minutes. Thereafter, the patient showed hemodynamically stable vital signs and uneventful condition. Finally he was discharged without any complications.
A 47-year-old Iranian woman presented to our hospital with the chief complaint of pain in the abdomen (mostly in the epigastric area) for the previous 2 days, associated with recurrent vomiting, nausea, and anorexia. Her complaints had started 2 hours after the accidental ingestion of a dental prosthesis about 2 days before admission (Fig. ). The patient has a known history of asthma and migraine headache and a history of wearing artificial dentures. At the time of admission, she was conscious and oriented to time, place, and person. Her pulse rate was 90 beats per minute, and her blood pressure was 100/60 mmHg. Her physical examination revealed severe epigastric and mild right upper quadrant abdominal tenderness.\nA radiograph showed no free gas under the right dome of the diaphragm and no air-fluid level (Fig. ). Ultrasonography revealed that there was no free fluid in the peritoneal cavity. Spiral abdominal computed tomography (CT) with oral and intravenous contrast revealed duodenal wall thickness in D2–4, peripheral mesenteric fat edema, hematoma in D1–3, air in the intestinal wall, pneumoretroperitoneum, laceration in D1–2 and a part of D3, and microperforations in D2–3. Because of the hematoma, narrowing in the primary and middle parts of the duodenum was seen (Figs. and ).\nVideo endoscopic findings were an old healed linear ulcer scar in the bulb of the duodenum, and also a swallowed lodged denture was seen in D2–3 after a papilla, which left a laceration behind. An attempt to capture the foreign body was not possible because of difficulty in the procedure and the chance of induced laceration, so a gastroenterologist recommended surgical evacuation of the denture. Laboratory investigation results are shown in Table .\nAfter preparation of the operation site, a midline laparotomy was performed. The stomach and small bowel were examined carefully for any perforation, but no pathology was revealed; however, a foreign body was palpable between the second and the third portions of the duodenum inside the lumen, so duodenal kocherization was performed to explore the duodenum for any perforations. There was no gross perforation in the duodenal wall, so the foreign body was pushed through the lumen to pass back to the stomach from the pylorus. A gastrostomy was performed, and the foreign body was removed and identified as an artificial denture (Fig. ). Then the stomach was repaired in two layers. Washing with normal saline was done, and an abdominal drain was placed at the duodenal site of kocherization. The patient recovered well postoperatively and was discharged on the ninth day of her total hospitalization in good condition.