[Perforated duodenal ulcer: laparoscopic treatment of perforation and ulcerous disease]

Duodenal ulcer perforation: a district hospital experience

BACKGROUND

Duodenal ulcer perforation still occurs frequently in the 21st century inspite of the wide availability of proton pump inhibitors.

METHOD

During 2005-2008, 34 patients underwent treatment of duodenal ulcer perforation at the University Hospital Lewisham, London. Laparoscopic or open repair of the perforation was used. In this study, we analysed the outcome of treatment in terms of complications, mortality and hospital stay with relevant to laparoscopy and open approach.

RESULTS

Ten patients underwent laparoscopic closure and the remaining 24 patients underwent laparotomy. The mean hospital stay for the laparoscopic group was 6.6 days and for open repair group was 12.8 days. There were two wound infection related to open approach and four patients died during the post operative period however the cause of death was not related to the procedure.

DISCUSSION

Laparoscopy has the advantage of avoiding a big incision and will enable the patient to get discharged home early. However, the only limiting factor is availability of expertise and competency of the surgeon.

Technical feasibility of laparoscopic Finney pyloroplasty examined in a canine model

The efficacy of laparoscopic surgery in the treatment of chronic duodenal ulcer has been demonstrated using minimally invasive approaches. This study aimed to evaluate the technical feasibility of laparoscopic Finney pyloroplasty in six dogs. Under laparoscopic guidance, the anastomosis was created using mechanical devices (n = 3) and combining a linear stapler device and intracorporeal suturing (n = 3). The operative time and complications were recorded. Evaluation of the anastomosis included studies of intraoperative and postoperative endoscopy and ultrasonography as well as the complete gastric emptying time. The animals were killed 4 weeks after surgery. Measurement of luminal diameter, amount of adhesion formation, degree of healing, and inflammation or fibrosis were evaluated in the postmortem studies. The operation was successfully completed for all the animals. No intraoperative or postoperative complications were observed. Gastric emptying was significantly enhanced in the postoperative period, as compared with the preoperative results. After 1 month, there was no evidence of anastomotic leak dehiscence at the gastroduodenal anastomosis. Luminal diameter was increased, and no abnormal findings were encountered during the postmortem abdominal exploration. The technical feasibility of performing a safe laparoscopic pyloroplasty in a dog model was demonstrated in this study.

Abdominal emergencies: diagnostic and therapeutic laparoscopy

BACKGROUND

Laparoscopy has been practiced in the management of emergencies resulting from inflammatory conditions, lumenal obstruction, perforation, vascular occlusion, and trauma. This article identifies and discusses controversial areas in the field, in particular surrounding the efficacy, cost effectiveness, and perceived advantages of laparoscopy in the evaluation and treatment of patients with acute abdominal conditions.

MATERIALS AND METHODS

Review and commentary on pertinent articles in the English language literature are presented.

RESULTS

Prospective randomized trials have been reported in the treatment of some disorders, but a lack of recommendations that are evidence-based has hindered more widespread usage of laparoscopy in an emergency setting. In addition, concerns have been raised that the creation of capnoperitoneum in the patient with established peritonitis may be detrimental with respect to potentiation of bacteremia and severe sepsis, and experimental studies have yielded conflicting data in this regard.

CONCLUSION

As such issues are resolved, utilization of laparoscopy is likely to increase substantially as expertise is acquired. A minimal-access approach carries less morbidity and may offer other practical advantages in terms of surgical technique and application. When surgical intervention is appropriate, laparoscopy is now preferred for acute biliary disease. Female patients of reproductive age with acute appendicitis may benefit, particularly if there is preoperative diagnostic uncertainty. Selected cases of intestinal obstruction and visceral perforation presenting soon after symptom onset and in whom shock is absent may also be amenable to laparoscopic repair. Its use in the treatment of most trauma patients and patients with generalized peritonitis or hemodynamic instability is not recommended at present.

[Treatment of perforated gastroduodenal ulcer by simple suture followed by Helicobacter pylori eradication]

AIMS OF THE STUDY

To determine the prevalence of Helicobacter pylori (HP) infection in Vietnam in case of perforated gastro-duodenal ulcer and to evaluate efficiency of medical treatment to obtain eradication of HP and ulcer healing.

PATIENTS AND METHODS

One hundred and eleven patients with perforated gastro-duodenal ulcer underwent surgical suture. HP infection was diagnosed by urease test and pathologic examination of peroperative antral biopsies, and by postoperative detection of HP-specific immunoglobulins G. HP infection was defined by positivity of at least one test. Medical treatment included omeprazole, clarithromycin, and amoxicillin for 7 days followed by omeprazole for 3 weeks for duodenal ulcer and 5 weeks for gastric ulcer. Follow-up endoscopy with biopsies was performed 4 to 6 weeks after treatment cessation.

RESULTS

Among 111 patients, 107 (96%) were infected by HP. The 4 patients non-infected by HP were treated by omeprazole alone and excluded from the study. Ulcer healed in 99 patients (93%). HP eradication was obtained in 102 patients (95%). The 8 patients with a non-healed ulcer and the 5 patients in whom HP eradication was not obtained at the first endoscopic control received additional medical treatment. Ultimately HP eradication and ulcer healing were obtained in all cases.

CONCLUSION

In a country in which prevalence of HP infection is high, acid-reduction surgery is unnecessary in case of perforated gastro-duodenal ulcer treated by simple surgical closure.

[Laparoscopic treatment of perforated duodenal ulcers. Results of a retrospective multicentric study. French Society of Laparoscopic Surgery]

STUDY AIM

The aim of this multicentric retrospective study was to report procedures, mortality and morbidity rate in a series of patients operated on for perforated duodenal ulcer with a laparoscopic approach.

PATIENTS AND METHODS

Four-hundred and nineteen patients from 18 centers were included. The duration of the study was ten years (1990 to 1999). There were 299 men and 120 women aged from 19 to 98 years (mean: 48 years). The ASA scores were as follows: I (48.7%), II (31.3%), III (17.5%), IV (2.5%). The mean duration between the onset of perforation and the time of operation was 13.4 hours (range: 1-70). The surgical procedures were suture (76.7%), epiploplasty (9.9%), only irrigation of the abdominal cavity (2.7%).

RESULTS

Conversion into laparotomy was performed in 10.6% of the patients. Mean operative time was 85 minutes. The morbidity and mortality rates were 13.4 and 1.4% respectively. Seventeen patients were reoperated because of fistula (n = 5), intra-abdominal abscess (n = 5), small bowel obstruction (n = 4), bleeding ulcer (n = 1), iatrogenic perforation of the gallbladder (n = 1) and small bowel (n = 1). Mean hospital stay was 8.5 days. All patients were discharged with a medical treatment of the peptic ulcer disease and in most of the cases, with antibiotics for Helicobacter pylori eradication. Six patients out of 96 with a medical history of chronic peptic ulcer underwent a vagotomy.

CONCLUSION

Laparoscopic repair of perforated duodenal ulcer is a safe option providing low rates of morbidity, reoperation and mortality, and can be considered the treatment of choice.