The “stamp method”: a new treatment for perforated peptic ulcer?

[Perforated peptic ulcer closure: laparoscopic or open?]

AIM

To compare laparoscopic and open closure of perforated peptic ulcer (PPU).

MATERIAL AND METHODS

The study included 153 patients who underwent PPU suturing. 78 patients underwent laparoscopic closure (laparoscopic group) and open suturing via upper midline laparotomy was performed in 75 cases (open group). Surgery time, postoperative pain severity, time of analgesics intake, postoperative complications, hospital-stay and and cosmetic effect were compared.

RESULTS

Laparoscopic PPU closure may be effective and accessible in experienced endoscopic surgeon. It significantly reduces postoperative pain severity, need for analgesics, incidence of postoperative complications and provides excellent cosmetic effect. However, there is greater time of surgery compared with open intervention. There were no significant differences in hspital-stay between groups.

CONCLUSION

Laparoscopic PPU suturing can be considered a good alternative to open surgery. Further researches are needed for standardization, assessment of safety, real advantages and disadvantages of laparoscopic technique.

Repair of gastric defects with an equine pericardial patch

PURPOSES

The objective of this study was to test the efficacy of an equine pericardial patch for repairing full-thickness defects of the stomach wall.

METHODS

Circular defects, 1.5 cm in diameter, were created on the anterior wall of the stomach of 12 female New Zealand rabbits. The defects were repaired by an equine pericardial patch. After euthanasia at different time intervals (3 days to 8 weeks) a macroscopic evaluation of the abdominal cavity (including adhesion scoring), mechanical testing and a histological examination of the stomach were performed.

RESULTS

The animals survived the surgical procedure and underwent an uneventful recovery until euthanasia. None of the patches failed. Adhesions were observed in all animals and were significant in 3/12 animals. Bursting pressure testing indicated that the repair was durable and that adequate strength to prevent patch failure was achieved by the second week. A histological examination showed gradual narrowing of the perforation site by mucosal and limited muscular regeneration.

CONCLUSIONS

The equine pericardial patch was successfully used to repair a gastric defect in our experimental model, and it seems that it could have potential as a material suitable for further research concerning the repair of upper gastrointestinal defects.

Strategies to improve the outcome of emergency surgery for perforated peptic ulcer

BACKGROUND

Perforated peptic ulcer (PPU) is a common surgical emergency that carries high mortality and morbidity rates. Globally, one-quarter of a million people die from peptic ulcer disease each year. Strategies to improve outcomes are needed.

METHODS

PubMed was searched for evidence related to the surgical treatment of patients with PPU. The clinical registries of trials were examined for other available or ongoing studies. Randomized clinical trials (RCTs), systematic reviews and meta-analyses were preferred.

RESULTS

Deaths from peptic ulcer disease eclipse those of several other common emergencies. The reported incidence of PPU is 3.8-14 per 100,000 and the mortality rate is 10-25 per cent. The possibility of non-operative management has been assessed in one small RCT of 83 patients, with success in 29 (73 per cent) of 40, and only in patients aged less than 70 years. Adherence to a perioperative sepsis protocol decreased mortality in a cohort study, with a relative risk (RR) reduction of 0.63 (95 per cent confidence interval (c.i.) 0.41 to 0.97). Based on meta-analysis of three RCTs (315 patients), laparoscopic and open surgery for PPU are equivalent, but patient selection remains a challenge. Eradication of Helicobacter pylori after surgical repair of PPI reduces both the short-term (RR 2.97, 95 per cent c.i. 1.06 to 8.29) and 1-year (RR 1.49, 1.10 to 2.03) risk of ulcer recurrence.

CONCLUSION

Mortality and morbidity from PPU can be reduced by adherence to perioperative strategies.

Laparoscopic versus open management of duodenal perforation: a comparative study at a District General Hospital

INTRODUCTION

Duodenal perforation is one of the common pathologies in patients presenting in emergency with acute abdominal pain in an emergency ward and requires prompt surgery as life saving and curative intervention. The present study was conducted to determine whether the minimal access approach by laparoscopy was equally feasible as the open method.

AIM

To compare laparoscopic vs. open management duodenal perforation in all aspects.

MATERIAL AND METHODS

INCLUSION CRITERIA

patients presenting to the emergency ward with acute pain in the abdomen with clinical signs of peritonitis and air under the diaphragm on X-ray abdomen standing were selected. Exclusion criteria were: patient age < 15 years and > 70 years, presentation > 2 days, shock with systolic blood pressure < 90 mm Hg which did not improve after hydration with 2000 ml of Ringer lactate solution, respiratory distress, history of cardiac disorder or respiratory disorders such as ischemic heart disease, arrhythmias, chronic obstructive pulmonary disease or asthma, bleeding and clotting disorders, pregnancy in females, previous upper abdominal surgery, and intra-operatively patients having perforation other than duodenal perforation. After excluding patients fitting the above criteria, two groups - test and control - were formed.

RESULTS

We found that complications both early and late were significantly fewer in patients treated by laparoscopy. Thus laparoscopy was both feasible and had comparable mortality and leakage rate.

CONCLUSIONS

Laparoscopic management of perforated duodenal ulcer is feasible, effective and decreases morbidity and overall treatment time and cost if performed in properly selected patients.

Emergent laparoscopy in treatment of perforated peptic ulcer: a local experience from a tertiary centre in Saudi Arabia

Background/ purpose

Perforated peptic ulcer (PPU) is still an existing disease that occurs frequently in the 21st century despite of the wide availability of antiulcer medication and Helicobacter eradication. The current study aimed to evaluate the hypothesis that its outcome might be improved by using the laparoscopy. The outcome of treatment in terms of complications, mortality and hospital stay with relevant to laparoscopy was analyzed.

Patients and methods

This prospective descriptive study was carried on the period of 3 years from July 2009 till July 2012. All patients with acute abdominal pain that was clinically diagnosed as having perforated peptic ulcer were included. Excluded from this study were those patients with concomitant bleeding from the ulcer and evidence of gastric outlet obstructions. Also excluded were those with evidence of large perforation more than 10 mm and patients with symptoms of more than 36 h durations for fear of septic shock.

Results

Forty seven patients were studied out of a total 53 PPU patients; they were 41 males and 6 females with the male to female ratio of 6.8:1. Their age ranged from 19 to 55 years with the mean age of 39.5 ± 8.6 years. Forty five patients were successfully treated by laparoscopy while only 2 cases that were early presented with signs of hypovolumic shock were converted into laparotomy due to severe bleeding. The mean hospital stay was 75 ± 12.6 h. Post operative complications included death of one patient in the postoperative period at the Intensive care unit (ICU) plus post operative fever in the 2 patients who underwent laparotomy and it was amenable to treatment.

Conclusions

Laparoscopic repair of a perforated peptic ulcer is an amenable and feasible technique within the hands of experienced laparoscopic surgeon when the cases are early and properly diagnosed.

Comparison of closure of gastric perforation ulcers with biodegradable lactide-glycolide-caprolactone or omental patches

Results of both methods of gastric closure (omental and biodegradable patch) were similar suggesting that a biodegradable patch glued to the outside of the stomach may be a viable alternative for closure of perforations of the digestive tract.

Background:

The current treatment of perforated peptic ulcers is primary closure, supported by the application of an omental patch. It is difficult and time consuming to perform this procedure by laparoscopic surgery, largely because of the required suturing. It was our aim to develop and test a new method of closure for gastric perforation that is similar in efficacy and safety to a traditional repair. This technique could have utility in laparoscopic repair, as it does not require sutures or mobilization of the omentum.

Method:

The new method, called the “stamp” method consists of closure of the perforation by gluing a biodegradable patch made of lactide-glycolide-caprolacton (LGC, Polyganics, B.V. Groningen, The Netherlands) on the outside of the stomach. It was compared with the omental patch procedure. Perforations were made in the stomach of 20 rats and closed by either method (10 rats in each group). The rats were followed for 10 weeks.

Results:

No complications were seen in any of the rats. In both groups, histological degradation of the patch by giant cells started at week 2. No signs of inflammation existed in either group. Signs of closure of the mucosa were seen after 2 weeks, and the muscular layer started to regenerate after 8 weeks in both groups.

Conclusion:

Results of both methods were similar, which means that treatment of a gastric perforation through the application of a biodegradable patch to the outside of the stomach is a feasible option and might even be an interesting technique for closure of other perforations in the digestive tract.

Randomized clinical trial of laparoscopic versus open repair of the perforated peptic ulcer: the LAMA Trial

BACKGROUND

Laparoscopic surgery has become popular during the last decade, mainly because it is associated with fewer postoperative complications than the conventional open approach. It remains unclear, however, if this benefit is observed after laparoscopic correction of perforated peptic ulcer (PPU). The goal of the present study was to evaluate whether laparoscopic closure of a PPU is as safe as conventional open correction.

METHODS

The study was based on a randomized controlled trial in which nine medical centers from the Netherlands participated. A total of 109 patients with symptoms of PPU and evidence of air under the diaphragm were scheduled to receive a PPU repair. After exclusion of 8 patients during the operation, outcomes were analyzed for laparotomy (n = 49) and for the laparoscopic procedure (n = 52).

RESULTS

Operating time in the laparoscopy group was significantly longer than in the open group (75 min versus 50 min). Differences regarding postoperative dosage of opiates and the visual analog scale (VAS) for pain scoring system were in favor of the laparoscopic procedure. The VAS score on postoperative days 1, 3, and 7 was significant lower (P < 0.05) in the laparoscopic group. Complications were equally distributed. Hospital stay was also comparable: 6.5 days in the laparoscopic group versus 8.0 days in the open group (P = 0.235).

CONCLUSIONS

Laparoscopic repair of PPU is a safe procedure compared with open repair. The results considering postoperative pain favor the laparoscopic procedure.