Effect of a pneumoperitoneum on the extent and severity of peritonitis induced by gastric ulcer perforation in the rat

Laparoscopic Repair for Perforated Peptic Ulcer: A Retrospective Study

BACKGROUNDS

The incidence of patients presenting with perforated peptic ulcers (PPU) has decreased during the last decades. At the same time, a laparoscopic approach to this condition has been adopted by increased number of surgeons. The aim of this study was to evaluate the early postoperative results of the laparoscopic treatment of perforated peptic ulcer performed in eight Romanian surgical centers with extensive experience in laparoscopic surgery.

METHODS

Between 2009 and 2013, 297 patients with perforated peptic ulcer were operated in the eight centers participating in this retrospective study. The patients' charts were reviewed for demographics, surgical procedure, complications and short-term outcomes.

RESULTS

Boey score of 0 was found in 122 patients (41.1%), Boey 1 in 169 (56.9%), Boey 3 in 6 (2.0%). For 145 (48.8%) patients, primary suture repair was performed, in 146 (49.2%) primary suture repair with omentopexy. There were 6 (2.0%) conversions to open surgery. The operative time was between 25 and 120 min, with a mean of 68 min. Two (0.7%) deaths were noted. Mean hospital stay was 5.5 days, ranges 3-25 days. Postoperative complications included: 7 (2.4%) superficial surgical site infections, 5 (1.6%) cardiovascular, 3 (1.0%) pulmonary, 2 (0.7%) duodenal leakages, 3 (1.0%) deep space infections and 1 (0.3%) upper digestive hemorrhage.

CONCLUSIONS

This study shows that the laparoscopic approach for PPU is feasible; the procedure is safe, with no increased risk of duodenal fistulae or residual intraperitoneal abscesses. We now consider the laparoscopic approach for PPU as the "gold standard" in patients with Boey score 0 or 1.

Changing patterns in the surgical treatment of perforated duodenal ulcer - single centre experience

Introduction

Although the surgical treatment of patients with perforated duodenal ulcer is the method of choice, the introduction of effective pharmacotherapy has changed the surgical strategy. Nowadays less extensive procedures are chosen more frequently. The introduction of laparoscopic procedures had a significant impact on treatment results.

Aim

To present our experience in the treatment of perforated duodenal ulcer in two periods, by comparing open radical anti-ulcer procedures with laparoscopic ulcer repair.

Material and methods

The analysis covered patients operated on for perforated duodenal ulcer. Two groups of patients were compared. Group 1 included 245 patients operated on in the period 1980–1994 with a traditional method (pyloroplasty + vagotomy) before introduction of proton pump inhibitors (PPI). Group 2 included 106 patients treated in the period 2000–2014 with the laparoscopic technique supplemented with PPI therapy. Groups were compared in terms of patients’ demographic structure, operative time, complication rate and mortality.

Results

The mean operative time in group 1 was shorter than in group 2 (p < 0.0001). Complications were noted in 57 (23.3%) patients in group 1 and 14 (13.5%) patients in group 2 (p = 0.0312). Reoperation was necessary in 13 (5.3%) cases in group 1 and in 5 cases in group 2 (p = 0.8179). The mortality rate in group 1 was significantly higher than in group 2 (10.2% vs. 2.8%, p = 0.0192). In group 1, median length of hospital stay was 9 days and differed significantly from group 2 (6 days, p < 0.0001).

Conclusions

Within the last 30 years, significant changes in treatment of perforated peptic ulcer (PPU) have occurred, mainly related to abandoning routine radical anti-ulcer procedures and replacing the open technique with minimally invasive surgery. Thus it was possible to improve treatment results by reducing complication and mortality rates, and shortening the length of hospital stay. Although the laparoscopic operation is longer, it improves outcomes. In the authors’ opinion, in each patient with suspected peptic ulcer perforation, laparoscopy should be the method of choice.

Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer

The primary goal of this study was to describe epidemiology and management strategies of the perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and retrospective studies regarding the early results of surgery and the risk factors. The tertiary goal was to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The following is the spectrum of results of the prospective studies: median overall morbidity rate was slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified were the same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70 years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10 mm), and ulcers with friable edges are also considered as conversion risk factors.

Laparoscopic repair of perforated peptic ulcer: a meta-analysis

BACKGROUND

Laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years, but few data exist to support the superiority of the laparoscopic approach over open repair. The objective of the current study was to compare the safety and efficacy of open and laparoscopic repair of perforated peptic ulcer in an evidence-based approach using meta-analytical techniques.

METHODS

A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1990 and December 2002. Only studies in the English language comparing the outcomes of laparoscopic and open repair of perforated peptic ulcer were recruited. All reports were critically appraised with respect to their methodology and outcome. Data from all included studies were extracted using standardized data extraction forms developed a priori. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio where feasible and appropriate.

RESULTS

A total of 13 publications comprising 658 patients met the inclusion criteria. The overall success rate of laparoscopic repair was 84.7% (n = 249). Postoperative pain was lower after laparoscopic repair than after open repair, supported by a significant reduction in postoperative analgesic requirement after laparoscopic repair. Meta-analyses demonstrated a significant reduction in the wound infection rate after laparoscopic repair, as compared with open repair, but a significantly higher reoperation rate was observed after laparoscopic repair.

CONCLUSIONS

Evidence suggests that laparoscopic repair of perforated peptic ulcer confers superior short-term benefits in terms of postoperative pain and wound morbidity. This approach is as safe and effective as open repair. Laparoscopic Graham-Steele patch repair of perforated duodenal or justapyloric ulcer is beneficial for patients without Boey's risk factors.

Endoscope-Assisted Laparoscopic Repair of Perforated Peptic Ulcers

Laparoscopic repairs for perforated peptic ulcer (PPU) are likely to fail in patients with shock, gastric outlet obstruction, or large perforations. This prospective study was performed to evaluate a revised approach of laparoscopic repair with endoscopic assistance to treat these patients. Between April 2001 and February 2002, 30 consecutive patients with PPU were enrolled in this study. The mean age was 43.1 ± 12.2 years. Male to female ratio was 27:2. One patient was excluded from laparoscopic repair due to a gastric outlet obstruction. The other 29 patients were managed according to a protocol of preoperative upper endoscopy and laparoscopic intracorporeal suture repair with an omental patch. The average operative time was 58.1 ± 13.5 minutes (range, 36–96 min). The average diameter of perforation was 4.2 ± 2.0 mm (range, 1–12 mm). The average time to resume oral fluids was 3.2 ± 0.8 days (range, 2–8 days). The average hospital stay was 4.7 ± 1.1 days (range, 3–10 days). There was no leakage or mortality. Most patients did not receive parenteral analgesics postoperatively. We conclude that endoscope-assisted laparoscopic repair for PPU is safe and effective. This revised technique allows surgeons to exclude patients who are likely to fail the laparoscopic repair.

Peritoneal, systemic, and distant organ inflammatory responses are reduced by a laparoscopic approach and carbon dioxide versus air

BACKGROUND

Advantages of laparoscopic surgery have, among other factors, been attributed to a shorter length of abdominal incision and the use of CO2 versus air. An analysis of these factors taking pressure-induced alterations into account is lacking. The objective of the study was to determine the impact of laparoscopy and laparotomy with exposure to CO2 and room air under a similar pressure on local, systemic, and distant organ immune responses.

METHODS

Twenty piglets were randomized into four groups: CO2 laparoscopy, air laparoscopy, CO2 laparotomy, and air laparotomy. Laparotomy was performed in a sterile balloon pressurized similar to laparoscopy. Peritoneal interleukin-1, interleukin-6, tumor necrosis factor-a, and counts of polymorphnuclear cells (PMNs), and macrophages (MFs) were determined in abdominal lavage fluids at 0, 2, and 48 h. Macrophages were assessed for reactive oxygen species (ROS) production. Systemic responses were gauged by white blood cell count (WBC) and cytokines. Alveolar lavage was performed at 48 h to determine cytokine levels, cell counts, and MF ROS production. Blood, lavage fluids, and mesenteric lymph nodes were tested for bacterial translocation.

RESULTS

Regarding the peritoneal response, laparotomy versus laparoscopy when performed with CO2 significantly increased PMN and decreased the percentage of macrophages (%MF) up to 48 h. There was a significant increase in interleukin-6, and there was a fourfold increase in MF ROS production. Similar differences between the procedures were found with exposure to air. The use of air versus CO2 in laparoscopy, but not in laparotomy, resulted in an increase of peritoneal PMN and a decrease of the %MF up to 48 h. Air increased the local interleukin-6 release in both procedures and increased MF ROS production fourfold. Regarding the systemic response, laparotomy produced a significant increase in WBC, which was significantly more pronounced with exposure to air. No alteration of other systemic cytokines was seen. Regarding the pulmonary response, the number of MFs and MF ROS production were significantly increased after air versus CO2 laparoscopy. There were no such differences between the laparotomy groups. Regarding bacterial translocation, no bacteria were cultured from peritoneal fluids, lymph nodes, or blood.

CONCLUSIONS

Inflammatory responses were reduced by a laparoscopic approach and by exposure to CO2 versus air. Peritoneal responses were affected to a larger degree than systemic parameters. Laparotomy overruled the effects of CO2 on chemotaxis and distant organ injury but not on peritoneal cytokine release.

Lavage by laparoscopy fares better than lavage by laparotomy: experimental evidence

BACKGROUND

Although carbon dioxide (CO2) pneumoperitoneum is proposed increasingly for treatment of secondary peritonitis, associated deleterious effects have been reported in experimental models, with the hypothesis that increased intraperitoneal pressure might facilitate bacterial translocation. The purpose of this study was to compare the outcome (and qualitative microbiologic analysis) from peritonitis in rats after lavage by laparoscopy with the outcome after lavage by laparotomy.

METHODS

After determination of the standard innoculum for this study in 30 animals, 120 male Wistar rats received 1 ml of Escherichi coli 10(6) colony-forming unit (CFU), Bacteroides fragilis 10(7) CFU, Enterococcus faecalis 10(7) CFU in a sterile rat feces-barium sulfate suspension adjuvant, were anesthetized with intramuscular ketamine, and then underwent peritoneal lavage by either laparotomy (n = 60) or laparoscopy (n = 60). The duration of peritonitis defined two groups: group A: duration less than 3 h (n = 20) and group B: duration 3 h or more (n = 40). Both groups underwent successive lavage with 10-ml aliquots (total, 50 ml) of 0.9% saline solution at 37 degrees C. Five 2-ml samples of liquid lavage were drawn for culture and microbiologic analysis. Blood (0.2 ml) and peritoneal liquid lavage samples were incubated 48 h at 37 degrees C and cultured.

RESULTS

All the animals survived. Mean duration of peritoneal lavage was 13.2 min (range, 6-25 min) for laparoscopy and 9.7 min (range, 6-15 min) and for laparotomy. The difference was not statistically significant. The mean duration of operation was significantly longer with laparoscopy than with laparotomy: 44.5 min (range, 35-62 min) and 25 min (range, 16-40 min), respectively (p = 0.0001). The collected lavage volumes were not statistically different: 48.5 ml (range, 40-54 ml) and 46.7 ml (range, 37-56 ml), respectively. No statistically significant differences were found between the laparoscopy and laparotomy groups in terms of E. coli bacteremia, irrespective of peritonitis duration. The rates of positive blood culture for B. fragilis and E. faecalis were signficantly lower after laparoscopy than after laparotomy, both in the overall group (p = 0.025 and p = 0.045, respectively) and when duration of peritonitis exceeded 3 h (p = 0.001 and p = 0.044, respectively).

CONCLUSIONS

In this animal model of secondary peritonitis, lavage by laparoscopy was associated with less bacteremia for B. fragilis and E. faecalis than peritoneal lavage by laparotomy.

Laparoscopic surgery and the systemic immune response

OBJECTIVE

The authors review studies relating to the immune responses evoked by laparoscopic surgery.

SUMMARY BACKGROUND DATA

Laparoscopic surgery has gained rapid acceptance based on clinical grounds. Patients benefit from faster recovery, decreased pain, and quicker return to normal activities. Only more recently have attempts been made to identify the metabolic and immune responses that may underlie this clinical success. The immune responses to laparoscopy are now being evaluated in relation to the present knowledge of immune responses to traditional laparotomy and surgery in general.

METHODS

A review of the published literature of the immune and metabolic responses to laparoscopy was performed. Laparoscopic surgery is compared with the traditional laparotomy on the basis of local and systemic immune responses and patterns of tumor growth. The impact of pneumoperitoneum and insufflation gases on the immune response is also reviewed.

CONCLUSIONS

The systemic immune responses for surgery in general may not apply to laparoscopic surgery. The body's response to laparoscopy is one of lesser immune activation as opposed to immunosuppression.