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Amalia R, Vidyani A, I’tishom R, Efendi WI, Danardono E, Wibowo BP, Parewangi ML, Miftahussurur M, Malaty HM. The Prevalence, Etiology and Treatment of Gastroduodenal Ulcers and Perforation: A Systematic Review. J Clin Med 2024; 13:1063. [PMID: 38398375 PMCID: PMC10888557 DOI: 10.3390/jcm13041063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/31/2024] [Accepted: 02/09/2024] [Indexed: 02/25/2024] Open
Abstract
(1) Background: Gastroduodenal perforation (GDP) is a life-threatening condition caused by a spontaneous or traumatic event. Treatment should be based on the mechanism of damage, timing, location, extent of the injury, and the patient's clinical condition. We aimed to examine several etiologic factors associated with gastroduodenal perforation and to search for the best method(s) for its prevention and treatment. (2) Methods: We conducted extensive literature reviews by searching numerous studies obtained from PubMed, Science Direct, and Cochrane for the following keywords: gastroduodenal perforation, Helicobacter pylori, NSAIDs' use, side effects of GDP, laparoscopy, and surgery. The primary outcome was the reported occurrence of GDP. (3) Results: Using keywords, 883 articles were identified. After applying the inclusion and exclusion criteria, 53 studies were eligible for the current analyses, with a total number of 34,692 gastroduodenal perforation cases. Even though the risk factors of gastroduodenal perforation are various, the prevalence of H. pylori among patients with perforation is considerably high. As technology develops, the treatment for gastric perforation will also improve, with laparoscopic surgery having a lower mortality and complication rate compared to open surgery for GDP treatment. (4) Conclusions: H. pylori infection plays the most significant role in GDP, more than NSAIDs, surgery, chemotherapy, or transplantation. Treatment of H. pylori infection is essential to decrease the prevalence of GDP and speed up its recovery. However, urgent cases require immediate intervention, such as laparoscopic or open surgery.
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Affiliation(s)
- Rizki Amalia
- Department of Environmental and Preventive Medicine, Oita University Faculty of Medicine, Yufu 879-5593, Japan;
- Helicobacter pylori and Microbiota Study Group, Institute of Tropical Disease, Universitas Airlangga, Surabaya 60286, Indonesia;
| | - Amie Vidyani
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Reny I’tishom
- Department of Medical Biology, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
| | - Wiwin Is Efendi
- Department of Pulmonology and Respiratory Medicine, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
| | - Edwin Danardono
- Department of Surgery, Faculty of Medicine, Universitas Airlangga, Surabaya 60132, Indonesia;
| | - Bogi Pratomo Wibowo
- Department of Endocrinology, Saiful Anwar General Hospital, Malang 65111, Indonesia;
| | - Muhammad Lutfi Parewangi
- Division of Gastroenterology-Hepatology, Department of Internal Medicine, Faculty of Medicine, Hasanuddin University, Makassar 90245, Indonesia;
| | - Muhammad Miftahussurur
- Helicobacter pylori and Microbiota Study Group, Institute of Tropical Disease, Universitas Airlangga, Surabaya 60286, Indonesia;
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Universitas Airlangga, Surabaya 60115, Indonesia
| | - Hoda M. Malaty
- Division of Gastroentero-Hepatology, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Universitas Airlangga, Surabaya 60115, Indonesia
- Department of Medicine, Baylor College of Medicine, Houston, TX 77030, USA
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Arroyo Vázquez JA, Khodakaram K, Bergström M, Park PO. Stent treatment or surgical closure for perforated duodenal ulcers: a prospective randomized study. Surg Endosc 2020; 35:7183-7190. [PMID: 33258032 PMCID: PMC8599331 DOI: 10.1007/s00464-020-08158-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Accepted: 11/06/2020] [Indexed: 11/30/2022]
Abstract
Background Perforated peptic ulcer is a life-threatening condition. Traditional treatment is surgery. Esophageal perforations and anastomotic leakages can be treated with endoscopically placed covered stents and drainage. We have treated selected patients with a perforated duodenal ulcer with a partially covered stent. The aim of this study was to compare surgery with stent treatment for perforated duodenal ulcers in a multicenter randomized controlled trial. Methods All patients presenting at the ER with abdominal pain, clinical signs of an upper G-I perforation, and free air on CT were approached for inclusion and randomized between surgical closure and stent treatment. Age, ASA score, operation time, complications, and hospital stay were recorded. Laparoscopy was performed in all patients to establish diagnosis. Surgical closure was performed using open or laparoscopic techniques. For stent treatment, a per-operative gastroscopy was performed and a partially covered stent was placed through the scope. Abdominal lavage was performed in all patients, and a drain was placed. All patients received antibiotics and intravenous PPI. Stents were endoscopically removed after 2–3 weeks. Complications were recorded and classified according to Clavien-Dindo (C-D). Results 43 patients were included, 28 had a verified perforated duodenal ulcer, 15 were randomized to surgery, and 13 to stent. Median age was 77.5 years (23–91) with no difference between groups. ASA score was unevenly distributed between the groups (p = 0.069). Operation time was significantly shorter in the stent group, 68 min (48–107) versus 92 min (68–154) (p = 0.001). Stents were removed after a median of 21 days (11–37 days) without complications. Six patients in the surgical group had a complication and seven patients in the stent group (C-D 2–5) (n.s.). Conclusions Stent treatment together with laparoscopic lavage and drainage offers a safe alternative to traditional surgical closure in perforated duodenal ulcer. A larger sample size would be necessary to show non-inferiority regarding stent treatment.
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Affiliation(s)
- Jorge Alberto Arroyo Vázquez
- Department of Surgery, South Älvsborg Hospital, Brämhultsvägen 53, 501 82, Borås, Sweden. .,University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden.
| | - Kaveh Khodakaram
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Maria Bergström
- Department of Surgery, Halland Hospital, Varberg, Sweden.,University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
| | - Per-Ola Park
- Department of Surgery, Halland Hospital, Varberg, Sweden.,University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
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Sutureless onlay omental patch for the laparoscopic repair of perforated peptic ulcers. World J Surg 2015; 38:1917-21. [PMID: 24663480 DOI: 10.1007/s00268-014-2503-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Because the feasibility and safety of laparoscopic approaches for the treatment of perforated peptic ulcer (PPU) have been fully recognized, laparoscopic repair of PPU (LPPU) has become a widely accepted procedure. Following closure of a PPU, the rationale to add an omental patch is based on the assumptions that a patch may decrease the possibility of leakage and make the closure more secure. However, one of the often mentioned disadvantages of LPPU is that it requires a significantly longer operating time. The purpose of the present study was to evaluate the efficacy of LPPU with a sutureless onlay omental patch. METHODS Over 60 months, 43 patients underwent LPPU with sutureless onlay omental patch, and another 64 patients underwent LPPU with sutured omental patch. Patient demographics, operation parameters, and surgical outcomes were analyzed retrospectively. RESULTS All patients in both groups survived to the end of the study. There were no leaks in either group. The operating time and length of stay in the sutureless onlay omental patch group were significantly shorter than in the sutured omental patch group. CONCLUSIONS A sutureless onlay omental patch is as safe and effective as a sutured omental patch for the laparoscopic repair of PPU.
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Penn A, Wang W, Wang ZJ, Yee J, Webb EM, Yeh BM. Demographics and frequency of the intermittently upturned omentum at CT. Eur J Radiol 2013; 82:e637-40. [PMID: 23906439 DOI: 10.1016/j.ejrad.2013.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 05/23/2013] [Accepted: 06/29/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES To describe the demographics and frequency of the intermittently upturned omentum at CT. METHODS We retrospectively reviewed abdominal CT scans of 336 consecutive patients (189 men and 147 women) who were imaged between June 1 and June 17, 2010 and who had prior comparison scans. Readers recorded the presence or absence of an intermittently upturned omentum, defined as a thick rind of fat interposed between the liver and the anterior abdominal wall seen on one but not the other scan. At chart review, we recorded patient demographics and other clinical characteristics (prior surgical history, presence of cirrhosis). RESULTS An intermittently upturned omentum was found in 10 of 336 (3.0%) patients. An intermittently upturned omentum was seen more commonly in men than in women (9 of 189 men, or 4.8% versus 1 of 147 women, or 0.7%, p=0.047) and in cirrhotics (4 of 37 cirrhotics, or 10.8% versus 6 of 299 non-cirrhotics, or 2.0%, p=0.023). In a sub-analysis of patients without prior abdominal surgery, this finding was again seen more commonly in men than women (7 of 163 men, or 4.3% versus 0 of 134 women, or 0%, p=0.018) and in cirrhotics (3 of 33 cirrhotics, or 9.1% versus 4 of 264 non-cirrhotics, or 1.5%, p=0.032). CONCLUSIONS An intermittently upturned omentum is not uncommon and is more frequently seen in men and in patients with cirrhosis who may have a larger anterior hepatic space.
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Affiliation(s)
- Alex Penn
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, Department of Radiology (AP, WW, ZJW, JY, EMW, BMY), University of California San Francisco, 505 Parnassus Avenue, San Francisco, CA 94143-0628, United States
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Sun G, Yang Y, Zhang X, Li W, Wang Y, Zhang L, Tang P, Kong J, Zhang R, Meng J, Wang X. Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study. Gastrointest Endosc 2013; 77:774-83. [PMID: 23453129 DOI: 10.1016/j.gie.2012.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reliable closure of the gastrotomy after transgastric natural orifice transluminal endoscopic surgery (NOTES) remains unresolved. OBJECTIVE To compare the technical aspects and clinical and histologic outcomes of NOTES gastrotomy closure techniques. DESIGN Experimental study. SETTING Animal laboratory. PATIENTS Thirty-four dogs, 14 for nonsurvival study and 20 for survival study. INTERVENTIONS The animals randomly received different gastrotomy closures after NOTES: endoclip, omentoplasty, over-the-scope-clip (OTSC), and hand-suturing. MAIN OUTCOME MEASUREMENTS Procedure time, closure strength, survival, postoperative adverse events, and histologic evaluation of wound healing. RESULTS Omentoplasty and OTSC groups needed shorter procedure times and fewer clips than the endoclip group. The endoclip and omentoplasty groups generated similar leakage pressures (34.5 ± 2.6 vs 42.2 ± 4.1 mm Hg, P > .05), both lower than OTSC and hand-suturing groups (81.5 ± 2.1 and 87.0 ± 3.0 mm Hg, respectively, P < .001). Of the 20 animals in the survival study (all 4 groups), only 2 of 6 in the endoclip group were killed prematurely due to sepsis. Necropsy revealed the OTSC group reached a 100% clip retention rate, higher than the endoclip (47.9%) and omentoplasty groups (44.4%, P < .05) rates. Complete healing, defined as intact and continuous gastric layers microscopically, was seen in 83.3% of animals (5 of 6) in the omentoplasty group, comparable with OTSC (4 of 6, 66.7%, P = .500) but higher than the endoclip group (1 of 6, 16.7%, P = .04). LIMITATIONS Animal study. CONCLUSIONS Omentoplasty is easier and safer for NOTES gastrotomy closure than endoclips and offers safety profile and efficacy similar to OTSC and hand-suturing.
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Affiliation(s)
- Gang Sun
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Wadaani HA. Emergent laparoscopy in treatment of perforated peptic ulcer: a local experience from a tertiary centre in Saudi Arabia. World J Emerg Surg 2013; 8:10. [PMID: 23497473 PMCID: PMC3614460 DOI: 10.1186/1749-7922-8-10] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2012] [Accepted: 01/29/2013] [Indexed: 11/22/2022] Open
Abstract
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.
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Affiliation(s)
- Hamed Al Wadaani
- Department of Surgery, College of Medicine, King Faisal University & King Fahd Hospital, Al- Ahsa, KSA.
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Feasibility of NOTES omental plug repair of perforated peptic ulcers: results from a clinical pilot trial. Surg Endosc 2013; 27:2201-8. [PMID: 23355151 DOI: 10.1007/s00464-012-2740-3] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Accepted: 12/04/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ulcer perforation carries up to a 30 % 1-year mortality rate. Intervention-related adverse events are among statistically significant predictors of 1-year mortality. A natural orifice transluminal endoscopic surgical (NOTES) approach may be less invasive and may decrease procedure-related adverse events by diminishing the so-called second hit, thus leading to decreased morbidity and mortality. We sought to assess the feasibility of an endoscopic transluminal omental plug technique in patients with perforated gastroduodenal ulcers under laparoscopic guidance. METHODS Patients with suspected acute gastroduodenal ulcer perforations were offered participation in this prospective pilot study. Closure of the perforation was attempted using the NOTES omental plug technique. Demographic, clinical, endoscopic, and radiographic data were abstracted, as were data for morbidity, mortality, and pilot data regarding quality of life (QOL). RESULTS From February 2010 through February 2012, a total of 17 patients presented to a tertiary care center with clinically suspected perforated ulcer. Of seven patients (mean age 79 years, range 64-89 years) who consented to the study, three underwent the study procedure. All patients had multiple comorbidities. Two patients presented with 4-6 mm perforated peptic ulcers and underwent successful laparoscopic-assisted NOTES omental and falciform ligament patch closure, respectively. Postoperative radiographic contrast studies showed no leak, and patients were discharged home on postoperative days 3 and 4. The third patient had undergone enterocutaneous fistula repair with herniorrhaphy 6 weeks before. Although a transluminal endoscopic approach was feasible, the omentum was under too much tension to be secured. This procedure was converted to an open omental patch repair. For all but one patient who provided consent, obtaining QOL data was feasible. CONCLUSIONS Initial results from a laparoscopic-assisted NOTES approach for closure of perforated peptic ulcers appear promising and enable swift recovery in selected patients. This is especially important in elderly and/or immunocompromised patients. Technical details and patient selection criteria continue to evolve.
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Lo HC, Wu SC, Huang HC, Yeh CC, Huang JC, Hsieh CH. Laparoscopic simple closure alone is adequate for low risk patients with perforated peptic ulcer. World J Surg 2011; 35:1873-8. [PMID: 21533964 DOI: 10.1007/s00268-011-1106-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Helicobacter pylori (H.P.) eradication has led to a significant decline in peptic ulcer prevalence; however, the number of patients requiring surgical intervention remains relatively unchanged. Laparoscopy suture repair is the most commonly used procedure for perforated peptic ulcer (PPU). Whether omental patch adds any benefit than simple closure alone is not answered. METHODS From July 2007 to August 2010, patients received emergency surgeries for PPU in our department were enrolled in this study. The demographic data, disease pattern, surgical outcomes were retrospectively collected. Patients who had previous multiple operations, with profound shock, and complicated ulcers were excluded. RESULTS Totally 73 patients were enrolled. 26 of them received simple closure and the other 47 received simple closure plus an omental patch. There were no difference in age, gender, ASA, Boey risk score, and incidence of co-morbidities. The Mannheim Peritonitis index, median operation time and length of stay were not different between groups. CONCLUSIONS In terms of leakage rate and surgical outcome, the maneuver to cover an omental patch on the repaired PPU did not show additional advantages compared to simple closure alone. Further prospective randomized study is required to clarify the safety and feasibility of simple closure alone without buttressing an omentum patch.
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Affiliation(s)
- Hung-Chieh Lo
- Department of Trauma and Emergency Surgery, China Medical University Hospital, China Medical University, No. 2 Yuh-Der Road, Taichung, 404, Taiwan
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Bonin EA, Moran E, Gostout CJ, McConico AL, Zielinski M, Bingener J. Natural orifice transluminal endoscopic surgery for patients with perforated peptic ulcer. Surg Endosc 2011; 26:1534-8. [PMID: 22179453 DOI: 10.1007/s00464-011-2063-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Accepted: 11/09/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Perforation accounts for 70% of deaths attributed to peptic ulcers. Laparoscopic repair is effective but infrequently used. Our aim was to assess how many patients with perforated peptic ulcer could be candidates for a transluminal endoscopic omental patch closure. METHODS This retrospective study reviewed patients with perforated peptic ulcer from 2005 to 2010. Demographics, ulcer characteristics, operative procedure, and outcomes were recorded. Candidates for endoscopic transluminal repair were defined as those having undergone omental patch closure of an ulcer of appropriate size and no contraindications to laparoscopy or endoscopy. RESULTS In the retrospective review, a total of 104 patients were identified; 62% female, mean age = 68 years, mean ASA of 3, and 63% medication-related ulcers. Fifty-nine (63%) had an omental patch (80% open), and 35 (37%) had other procedures. Ten patients had nonoperative management. Thirty-day mortality was 14% and 1 year mortality was 35%. Forty-nine patients (52%) were considered potential candidates for transluminal repair. CONCLUSION Sixty-three percent of our patients sustained a medication-related perforation with 1 year mortality of 35%. The majority of patients were treated using open omental patch repair. Transluminal endoscopic repair may provide an additional situation for a minimally invasive approach for a number of these patients.
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Affiliation(s)
- Eduardo A Bonin
- Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA
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Moran EA, Gostout CJ, McConico AL, Michalek J, Huebner M, Bingener J. Assessing the invasiveness of NOTES perforated viscus repair: a comparative study of NOTES and laparoscopy. Surg Endosc 2011; 26:103-9. [PMID: 21792716 DOI: 10.1007/s00464-011-1834-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Accepted: 06/22/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) repair of perforated peptic ulcers may decrease surgical invasiveness and improve patient outcomes. METHODS Full thickness gastrotomy was created laparoscopically in swine followed by soilage time. Repair proceeded with a laparoscopic (n = 14) or the NOTES (n = 14) approach. For NOTES repair, the omentum was endoscopically pulled into the gastric lumen and clipped. Intraoperative and postoperative parameters were recorded, including arterial blood gas (ABG) analysis and serum samples for white blood cell (WBC), TNF-α, IL-1, and IL-6 analysis. RESULTS Twenty-four of 28 animals thrived to study completion. NOTES repair could not be accomplished in one animal. At necropsy, all repairs were intact. Blood pressure was equivalent between groups. Pulse examined during the last 30 min of each procedure revealed a slightly higher mean pulse in the animals undergoing NOTES procedures (NOTES, 102 ± 28; laparoscopy, 83 ± 24). ABG obtained at the conclusion of the procedure revealed a pH of 7.47 in NOTES animals and 7.43 in the laparoscopy animals (p = 0.06), a change from baseline in both groups. The final pCO(2) was lower in the NOTES group (NOTES, 40.62; laparoscopy, 47.49, p = 0.03). WBC counts were comparable on postoperative day (POD) 1 (NOTES, 21.1; laparoscopy, 19.0; p = 0.49). Mean TNF-α serum levels were equivalent at all time points between groups; however, TNF-α varied significantly from baseline to POD 7 (p = 0.002). CONCLUSION NOTES omental repair appears comparable to that of laparoscopy. The lower arterial pCO(2) at the conclusion of the NOTES procedure may be advantageous in critically ill patients.
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Affiliation(s)
- E A Moran
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Affiliation(s)
- F Y Lui
- Section of Trauma, Surgical Critical Care and Surgical Emergencies, Yale University Department of Surgery, New Haven, CT 06520-8062, USA
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The role of endoscopy in the management of patients with peptic ulcer disease. Gastrointest Endosc 2010; 71:663-8. [PMID: 20363407 DOI: 10.1016/j.gie.2009.11.026] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Accepted: 11/13/2009] [Indexed: 12/13/2022]
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Moran EA, Gostout CJ, McConico AL, Bingener J. Natural orifice translumenal endoscopic surgery used for perforated viscus repair is feasible using lower peritoneal pressures than laparoscopy in a porcine model. J Am Coll Surg 2010; 210:474-9. [PMID: 20347740 DOI: 10.1016/j.jamcollsurg.2009.11.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2009] [Revised: 11/20/2009] [Accepted: 11/24/2009] [Indexed: 01/08/2023]
Abstract
BACKGROUND Procedure-related complications contribute to 1-year mortality in patients with perforated ulcers. Natural orifice translumenal endoscopic surgery (NOTES) might offer a new repair approach. STUDY DESIGN Swine were randomized to laparoscopic or NOTES repair. Laparoscopic gastrotomy creation (1 cm) was followed by 4 hours soilage time. After peritoneal cavity irrigation (per group assignment), repair proceeded with a laparoscopic or NOTES approach. For NOTES repair, omentum was endoscopically grasped, pulled into the gastric lumen, and fixed with metallic clips. Feasibility; time to complete procedures; pneumoperitoneal pressures; and clinical parameters, including necropsy and peritoneal culture at 2 weeks, were recorded. RESULTS NOTES repair failed in 1 animal (technical); repair was completed laparoscopically, and data were analyzed as intention to treat. Specific NOTES repair time (minutes) was comparable with laparoscopy (36 versus 46; p = 0.2). Mean abdominal pressure (mmHg) required to complete NOTES repair was lower than in laparoscopy (4 versus 12; p < 0.001). Nineteen of 23 animals thrived until necropsy at 2 weeks. Three animals succumbed to airway compromise in recovery; 1 NOTES animal failed to thrive on postoperative day 7. No intra-abdominal cause for these deaths was found. At necropsy all repairs were intact, and peritoneal cultures revealed a small and equivalent amount of colony-forming units in each group. CONCLUSIONS Endoscopic ulcer repair appears technically feasible with similar clinical and infectious outcomes to laparoscopy. The lower required pneumoperitoneal pressures used in these NOTES techniques are recognizable different outcomes from laparoscopy and can be advantageous in critically ill patients.
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Affiliation(s)
- Erica A Moran
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA
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Ersoy OF, Ozkan N, Celik A, Kayaoglu HA, Cakir E. Effect of cyanoacrylate on closure of gastric perforation: A comparative study in a rat model. MINIM INVASIV THER 2009; 18:225-31. [DOI: 10.1080/13645700903062387] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Vaidya BB, Garg CP, Shah JB. Laparoscopic repair of perforated peptic ulcer with delayed presentation. J Laparoendosc Adv Surg Tech A 2009; 19:153-6. [PMID: 19216695 DOI: 10.1089/lap.2008.0328] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Laparoscopic repair has been used to treat perforated peptic ulcers since 1990 and is gaining acceptance. The main concerns are postoperative intra-abdominal collections and performing laparoscopy in the presence of peritonitis. METHODS From June 2006 to June 2008, 31 patients presenting with a clinical diagnosis of perforated peptic ulcer with peritonitis who underwent laparoscopic omental patch repair were selected. Patients who presented more than 24 hours after the onset of pain were only included for this analysis. Conversion criteria were malignant ulcers, perforations larger than 10 mm, or for technical difficulties. The degree of peritonitis was noted and a thorough wash given. The perforation was repaired by the standard omental patch technique, and the number of sutures were decided according to the size of the perforation. Endpoints were operative time, postoperative pain, length of postoperative hospital stay, and complications. RESULTS There were 2 conversions due to technical difficulties. Laparoscopic repair required an average of 105 minutes to complete. The median postoperative stay was 5.5 days while mean duration of pain was 3 days. Four patients had port-site infections and 5 had intra-abdominal collections, which were managed conservatively. There were no chest infections or mortality in our series. CONCLUSIONS Laparoscopic repair of perforated peptic ulcer is a safe, reliable procedure even in delayed presentations with peritonitis. It has an acceptable morbidity and all the advantages of the minimally invasive surgical approach.
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Affiliation(s)
- Beena B Vaidya
- Department of Surgery, Government Medical College and New Civil Hospital, Surat, India
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Dray X, Giday SA, Buscaglia JM, Gabrielson KL, Kantsevoy SV, Magno P, Assumpcao L, Shin EJ, Reddings SK, Woods KE, Marohn MR, Kalloo AN. Omentoplasty for gastrotomy closure after natural orifice transluminal endoscopic surgery procedures (with video). Gastrointest Endosc 2009; 70:131-40. [PMID: 19394007 DOI: 10.1016/j.gie.2008.10.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2008] [Accepted: 10/14/2008] [Indexed: 12/16/2022]
Abstract
INTRODUCTION The utility of the greater omentum has not been assessed in transluminal access closure after natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE Our purpose was to evaluate the feasibility, efficacy, and safety of omentoplasty for gastrotomy closure. METHODS AND PROCEDURES Survival experiments in 9 female 40-kg pigs were randomly assigned to 3 groups: group A, endoscopic full-thickness resection (EFTR) for transgastric access and peritoneoscopy without closure; group B, ETFR and peritoneoscopy with omentoplasty (flap of omentum is pulled into the stomach and attached to the gastric mucosa with clips but no clips are used for gastrotomy closure itself); group C, balloon dilation for opening and peritoneoscopy followed by omentoplasty for closure. The animals were observed for 2 weeks and then underwent endoscopy and necropsy with histologic evaluation. RESULTS Transgastric opening and peritoneoscopy were achieved in all pigs. In groups B and C, a flap of omentum was easily placed to seal the gastrotomy and then attached to the gastric mucosa with 2 to 5 clips (median 4) in 7 to 20 minutes (median 15 minutes). In group A, peritonitis developed in all animals. In both groups B and C, all animals survived 15 days with no peritonitis and minimal adhesions outside the gastrotomy site. In addition, all achieved complete healing (transmural, n = 4; mucosal ulceration, n = 2) of the gastrotomy site. One animal in group B had an 18-mm abscess in the omental flap. LIMITATIONS Animal model, small sample size, lack of appropriate controls for group C. CONCLUSIONS Omentoplasty of the gastrotomy site is a technically feasible method to seal balloon-created transgastric access to the peritoneal cavity after NOTES procedures.
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Affiliation(s)
- Xavier Dray
- Division of Gastroenterology and Hepatology, Johns Hopkins School of Medicine, Baltimore, Maryland 21205, USA.
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17
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Song KY, Kim TH, Kim SN, Park CH. Laparoscopic repair of perforated duodenal ulcers: the simple "one-stitch" suture with omental patch technique. Surg Endosc 2007; 22:1632-5. [PMID: 18030520 DOI: 10.1007/s00464-007-9670-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2007] [Revised: 06/28/2007] [Accepted: 08/29/2007] [Indexed: 12/12/2022]
Abstract
BACKGROUND We present, here, the technique and results of our laparoscopic simple "one-stitch" suture with omental patch technique for treating 35 patients with perforated duodenal ulcer. METHODS The laparoscopic treatment included peritoneal lavage, suture of the perforation without knotting, and then tying the suture over the omentum. Follow-up gastroscopy was performed after an eight-week course of medication with proton-pump inhibitors. RESULTS Conversion to laparotomy was necessary for two patients, because of a large-sized perforation and the inadequate localization of the perforation site, respectively. The mean operative time was 64 minutes and the mean hospital stay was 6.8 days. Operation-related complications occurred in two patients, including one case of pneumonia and one case of gastric stasis. CONCLUSIONS This simple "one-stitch" suture with omental patch technique is a safe and easy procedure, and it has an acceptable morbidity rate and a low conversion rate.
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Affiliation(s)
- Kyo-Young Song
- Department of Surgery, The Catholic University of Korea, College of Medicine, 505 Banpo-dong, Seocho-gu, Seoul, Korea
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18
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Abstract
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.
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Affiliation(s)
- Frank J Branicki
- Department of Surgery, United Arab Emirates University, Al Ain, United Arab Emirates.
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19
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Jani K, Saxena AK, Vaghasia R. Omental plugging for large-sized duodenal peptic perforations: A prospective randomized study of 100 patients. South Med J 2006; 99:467-71. [PMID: 16711308 DOI: 10.1097/01.smj.0000203814.87306.cd] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Due to friable margins and the moribund state of the patient, managing giant duodenal perforations (>20 mm in diameter) is a challenging task. METHODS A prospective randomized study of 100 patients with large-sized (> 20 mm) duodenal peptic perforation comparing omental plugging (study group) with omentopexy (control group) was carried out. RESULTS Size of the perforation varied between 20 to 30 mm. No study group patients developed a postoperative perforation site leak, as compared with 6 patients in the control group. Gastric outlet obstruction was significantly less at 6 weeks and 5 years in the study group as compared with the control group, and mortality was significantly less in the study group. CONCLUSION It was concluded that omental plugging was a safe and reliable method of treatment for large-sized duodenal peptic perforations.
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Affiliation(s)
- Kalpesh Jani
- Department of Surgery, Medical College & SSG Hospital, Baroda, India.
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20
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Bertleff MJOE, Liem RSB, Bartels HL, Robinson PH, Van der Werff JFA, Bonjer HJ, Lange JF. The “stamp method”: a new treatment for perforated peptic ulcer? Surg Endosc 2006; 20:791-3. [PMID: 16544084 DOI: 10.1007/s00464-004-2157-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Accepted: 02/11/2005] [Indexed: 01/15/2023]
Abstract
BACKGROUND The aim of this study was to develop a simple method for closure of a perforated peptic ulcer, making it more accessible for laparoscopic surgery. METHODS An experimental pilot study was performed using five male Wistar rats. The perforation was closed by a bioabsorbable patch made of lactide-glycolid-caprolactone fixed with glue onto the outside of the stomach. RESULTS Postoperatively, there were no signs of leakage or other complications. Histologically, there were no signs of inflammation on the inside of the stomach, and there was a 50% reduction of the perforation each successive postoperative week. No adverse reactions because of the degradable material or glue were observed. CONCLUSIONS Treatment of a perforated peptic ulcer by placing a patch of biodegradable material like a "stamp" on the outside of the stomach is a feasible option.
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Affiliation(s)
- M J O E Bertleff
- Department of Plastic Surgery, Academic hospital Groningen, Hanzeplein 1, P.O. Box 30001, Groningen, 9700 RB, The Netherlands.
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21
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Lunevicius R, Morkevicius M. Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer. World J Surg 2006; 29:1299-310. [PMID: 16132404 DOI: 10.1007/s00268-005-7705-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Raimundas Lunevicius
- 2nd Department of Abdominal Surgery, Clinic of General and Plastic Surgery, Orthopaedics, and Traumatology, Vilnius University Emergency Hospital, Vilnius University, Siltnamiu Street 29, LT-04130 Vilnius, Lithuania.
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22
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Kirshtein B, Bayme M, Mayer T, Lantsberg L, Avinoach E, Mizrahi S. Laparoscopic treatment of gastroduodenal perforations: comparison with conventional surgery. Surg Endosc 2005; 19:1487-90. [PMID: 16222472 DOI: 10.1007/s00464-004-2237-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2004] [Accepted: 05/10/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND Laparoscopic techniques have been proposed as an alternative to open surgery for the treatment of peptic ulcer perforation. This study compared the outcome of laparoscopic and open approaches for the repair of gastroduodenal perforations. METHODS A retrospective review was conducted with 134 consecutive patients treated for gastroduodenal perforations. These patients included 122 with perforated duodenal ulcers, 10 with perforated gastric ulcers, and 2 with iatrogenic duodenal perforations. Whereas 68 patients were treated laparoscopically, 66 patients underwent conventional (open) surgery. RESULTS Laparoscopic repair was successful in 65 cases (96 %). The mean operating time was shorter with the laparoscopic technique (68 vs 59 min), but the difference was not significant. The duration of postoperative nasogastric aspiration and time to resumed oral intake were shorter in the laparoscopic group (2.6 vs 4.1 days and 4.4 vs. 5.2 days, respectively; p = 0.043). The postoperative analgetic requirements, and overall complications rate were significantly lower after laparoscopic surgery (p = 0.03 and p = 0.004, respectively). There was no statistically significant difference in hospital stay (5.1 vs 6.1 days) or mortality rate between the two procedures. CONCLUSION Laparoscopic repair of gastroduodenal perforations is a safe alternative treatment offering certain significant short-term advantages.
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Affiliation(s)
- B Kirshtein
- Department of Surgery A, Soroka University Hospital, Post Office Box 151, Beer Sheva 84101, Israel.
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23
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Lunevicius R, Morkevicius M. Risk factors influencing the early outcome results after laparoscopic repair of perforated duodenal ulcer and their predictive value. Langenbecks Arch Surg 2005; 390:413-20. [PMID: 16041553 DOI: 10.1007/s00423-005-0569-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2005] [Accepted: 06/07/2005] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Clear patient selection criteria and indications for laparoscopic repair of perforated duodenal ulcers are necessary. The aims of our study are to report the early outcome results after operation and to define the predictive values of risk factors influencing conversion rate and genesis of suture leakage. PATIENTS/METHODS Sixty nonrandomly selected patients operated on laparoscopically in a tertiary care academic center between October 1996 and May 2004 for perforated duodenal ulcers were retrospectively analyzed. The primary outcome measures included the duration of symptoms, shock, underlying medical illness, ulcer size, age, Boey score, and the collective predictive value of these variables for conversion and suture leakage rates. RESULTS Laparoscopic repair was completed in 46 patients (76.7%). Fourteen patients (23.3%) underwent conversion to open repair. Eight patients (13.3%) had postoperative complications. Suture leakage was confirmed in four patients (6.7%). Hospital stay was 7.8+/-5.3 days. There was no mortality. Patients with an ulcer perforation size of >8 mm had a significantly increased risk for conversion to open repair (p<0.05): positive predictive value (PPV) 75%, sensitivity 27%, specificity 98%, and negative predictive value (NPV) 85%. The significance of ulcer perforation size was confirmed by a stepwise logistic regression test (p=0.0201). All patients who developed suture leakage had acute symptoms for >9 h preoperatively (p<0.001): PPV 31%, specificity 84%, sensitivity 100%, and NPV 100%. Conversions happened with surgeons whose previous experience involved 1.8+/-2.3 cases compared to 3.9+/-2.9 cases in successful laparoscopic repair (p=0.039, t test). CONCLUSIONS Ulcer perforation size of >8 mm is a significant risk factor influencing the conversion rate. An increase in the suture leakage rate is predicted by delayed presentation of >9 h.
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Affiliation(s)
- Raimundas Lunevicius
- Clinic of General and Plastic Surgery, Orthopaedics and Traumatology, Vilnius University, Siltnamiu str. 29, 04130, Vilnius, Lithuania.
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Siu WT, Chau CH, Law BKB, Tang CN, Ha PY, Li MKW. Routine use of laparoscopic repair for perforated peptic ulcer. Br J Surg 2004; 91:481-4. [PMID: 15048752 DOI: 10.1002/bjs.4452] [Citation(s) in RCA: 70] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Laparoscopic repair of perforated peptic ulcer was reported in 1990 but has not gained wide acceptance. The aim of this study was to evaluate the safety and efficacy of laparoscopic repair for perforated peptic ulcer in routine clinical practice. METHODS This was a prospective analysis of 172 patients who underwent laparoscopic repair of a perforated peptic ulcer between July 1997 and June 2003. RESULTS One hundred and seventy-two patients of mean age 54 (range 14-93) years had perforated peptic ulcer diagnosed by laparoscopy. There were 172 duodenal ulcers, 22 prepyloric and 13 non-juxtapyloric gastric ulcers. One hundred and sixty-five patients underwent omental patch closure of perforations; there were six Pólya gastrectomies and one ulcerectomy. Thirty-seven patients (21.5 per cent) required conversion to laparotomy. The mean operating time was 64.8 (range 14-180) min. The median postoperative requirement for intramuscular pethidine was one dose. The median postoperative hospital stay was 6 days. Complications occurred in 28 patients (16.3 per cent) resulting in three reoperations. Six patients with intra-abdominal collections were managed by percutaneous drainage. Two patients who underwent conversion developed a wound infection. Fourteen patients (8.1 per cent) died, 11 of whom were American Society of Anesthesiologists grade III and IV. CONCLUSION Laparoscopic repair of perforated peptic ulcer is a safe emergency procedure in routine clinical practice for patients with perforated pyloroduodenal ulcer.
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Affiliation(s)
- W T Siu
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, China.
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25
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Lee KH, Chang HC, Lo CJ. Endoscope-Assisted Laparoscopic Repair of Perforated Peptic Ulcers. Am Surg 2004. [DOI: 10.1177/000313480407000417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- Kun-Hua Lee
- From the Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Hung-Chi Chang
- From the Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Chong-Jeh Lo
- From the Division of General Surgery, Changhua Christian Hospital, Changhua, Taiwan
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26
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Abstract
Iatrogenic perforation of the gastrointestinal tract is a medical emergency and is inevitable. An endoscopist must maintain a high index of suspicion despite minimal or atypical symptoms and negative radiologic studies, because perforation is a complication with tremendous morbidity and mortality. The endoscopist must know how to manage this complication appropriately and to seek immediate surgical consultation. There is ongoing controversy about when a patient should undergo nonoperative or surgical therapy. An evidence-based approach to manage iatrogenic perforation is not possible. The trend in the modern era is to less invasive, nonoperative therapy, given advancements in ICU care and antibiotics. Laparoscopy or laparoscopic-assisted (minilaparotomy) surgery is also being increasingly used with outcomes comparable with conventional laparotomy. Experience and advancements in accessories have enabled endoscopic repair of iatrogenic perforation in many situations [84]. The management algorithms provided synthesize the pertinent literature into reasonable guidelines to follow. Ultimately, an individualized approach must be taken to manage the patient with an iatrogenic perforation.
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Affiliation(s)
- Rajesh V Putcha
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center at Dallas, Room F.4.310, 5323 Harry Hines Boulevard, Dallas, TX 75390-8887, USA
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27
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Köninger J, Böttinger P, Redecke J, Butters M. Laparoscopic repair of perforated gastroduodenal ulcer by running suture. Langenbecks Arch Surg 2003; 389:11-6. [PMID: 14618328 DOI: 10.1007/s00423-003-0427-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2003] [Accepted: 08/25/2003] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND AIMS Perforated gastroduodenal ulcer represents an emergency situation that requires immediate surgical intervention. Laparoscopic ulcer repair is a feasible and safe procedure, especially in cases of a short duration of ulcer perforation and good clinical condition. However, to be well accepted as a treatment modality, an endoscopic procedure should be as simple as possible. We describe a technique that does not require intra-corporal or extra-corporal knotting. PATIENTS AND METHODS Over a 4-year period, we performed 786 diagnostic laparoscopies for various, acute abdominal conditions. We identified 20 gastroduodenal perforations. All ulcers were closed with a one-row running suture (Lahodny) and controlled radiologically on the third postoperative day. RESULTS Three different surgeons performed the surgeries. There were no conversions to open surgery. Median operating time was 50 min, and median hospital stay was 9 days. We observed no insufficiency, no wound infection, and no stenosis or persisting peritonitis. CONCLUSION The closure of perforated gastric ulcers with the Lahodny suture is safe and simple to perform.
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Affiliation(s)
- Jörg Köninger
- Abteilung für Allgemein- und Viszeralchirurgie, Krankenhaus Bietigheim, Riedstrasse 12, 74321, Bietigheim-Bissingen, Germany,
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28
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Gallardo A, Rosado R, Ramírez D, Medina P, Mezquita S, Sánchez J. Rupture of the lesser gastric curvature after a Heimlich maneuver. Surg Endosc 2003; 17:1495. [PMID: 12811657 DOI: 10.1007/s00464-003-4206-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2003] [Accepted: 02/19/2003] [Indexed: 11/26/2022]
Abstract
BACKGROUND We present a case of lesser gastric curvature injury after a Heimlich maneuver due to obstruction of the breathing tract that was repaired by laparoscopic surgery. METHODS A patient with perforation of the lesser gastric curvature as a result of closed abdominal traumatism was operated on using the laparoscopic approach with the use of four trocars as work openings. With this technique, the diagnosis was confirmed, the injury repaired, and the abdominal cavity washed. RESULTS The postoperative period was favorable and the patient was released from the hospital on day 7 without any complications. CONCLUSIONS Laparoscopic surgery can be technically reproduced in the treatment of gastric injury as a result of closed abdominal traumatism.
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Affiliation(s)
- A Gallardo
- Department of Surgery, Huércal-Overa Hospital, Dr Parra Ave., 04600 Huércal-Overa, Almería, Spain
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29
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Gisbert JP, Pajares JM. Helicobacter pylori infection and perforated peptic ulcer prevalence of the infection and role of antimicrobial treatment. Helicobacter 2003; 8:159-67. [PMID: 12752726 DOI: 10.1046/j.1523-5378.2003.00139.x] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Although the role of Helicobacter pylori infection on noncomplicated peptic ulcer disease has been definitively established, the precise relationship between the organism and complicated ulcer has hardly been studied. The mean prevalence of H. pylori infection in patients with perforated peptic ulcer is of only about 65-70%, which contrasts with the almost 90-100% figure reported in noncomplicated ulcer disease. However, H. pylori infection rates in various studies range markedly from 0% to 100%, suggesting that differences in variables as number and type of diagnostic methods used to diagnose H. pylori infection, or frequency of nonsteroidal anti-inflammatory drug intake, may be responsible for the low prevalence reported in some studies. Recurrent ulcer disease after peptic ulcer perforation mainly occurs in patients with H. pylori infection, which suggests that the microorganism plays an important role in this complication. All patients with perforated peptic ulcer should be treated by simple closure of the perforation and with therapy aimed at healing of the ulcer and eradicating the H. pylori infection, as disappearance of the organism prevents, or at least decreases, ulcer recurrence and ulcer perforation in patients with H. pylori-associated perforated ulcers after simple closure. Therefore, H. pylori eradicating treatment should be started during the immediate postoperative period. The patients with intractable recurrent symptoms of peptic ulcer despite adequate medical treatment, but without H. pylori infection (e.g. a patient using nonsteroidal anti-inflammatory drugs), is probably the only remaining indication for elective definitive surgical treatment of peptic ulcer disease.
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Affiliation(s)
- Javier P Gisbert
- Department of Gastroenterology. University Hospital of 'La Princesa', Madrid, Spain
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30
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Jeong JG. Minimally Invasive Surgery Available in Primary and Secondary Care Hospitals. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2003. [DOI: 10.5124/jkma.2003.46.8.678] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Jong Gill Jeong
- Department of General Surgery, Yosu Chonnam Hospital, Korea.
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31
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Abstract
Patients with longer duration of huge gastroduodenal perforation are known to be difficult to tolerate major surgery. Primary closure of the perforation will result in suture tension with high risk of dehiscence, gastric outlet obstruction, and even mortality. Teflon-Felt is a bioinert, polytetrafluoroethylene, flexible material used on patients with vascular defect. It is proposed that Teflon-Felt may be an optimal material for closure of giant gastroduodenal perforation to reduce suture tension without narrowing of the gastric outlet.
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Affiliation(s)
- S-P Kung
- Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan, ROC.
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Siu WT, Leong HT, Law BKB, Chau CH, Li ACN, Fung KH, Tai YP, Li MKW. Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial. Ann Surg 2002; 235:313-9. [PMID: 11882751 PMCID: PMC1422436 DOI: 10.1097/00000658-200203000-00001] [Citation(s) in RCA: 184] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare the results of open versus laparoscopic repair for perforated peptic ulcers. SUMMARY BACKGROUND DATA Omental patch repair with peritoneal lavage is the mainstay of treatment for perforated peptic ulcers in many institutions. Laparoscopic repair has been used to treat perforated peptic ulcers since 1990, but few randomized studies have been carried out to compare open versus laparoscopic procedures. METHODS From January 1994 to June 1997, 130 patients with a clinical diagnosis of perforated peptic ulcer were randomly assigned to undergo either open or laparoscopic omental patch repair. Patients were excluded for a history of upper abdominal surgery, concomitant evidence of bleeding from the ulcer, or gastric outlet obstruction. Patients with clinically sealed-off perforations without signs of peritonitis or sepsis were treated without surgery. Laparoscopic repair would be converted to an open procedure for technical difficulties, nonjuxtapyloric gastric ulcers, or perforations larger than 10 mm. A Gastrografin meal was performed 48 to 72 hours after surgery to document sealing of the perforation. The primary end-point was perioperative parenteral analgesic requirement. Secondary endpoints were operative time, postoperative pain score, length of postoperative hospital stay, complications and deaths, and the date of return to normal daily activities. RESULTS Nine patients with a surgical diagnosis other than perforated peptic ulcer were excluded; 121 patients entered the final analysis. There were 98 male and 23 female patients recruited, ages 16 to 89 years. The two groups were comparable in age, sex, site and size of perforations, and American Society of Anesthesiology classification. There were nine conversions in the laparoscopic group. After surgery, patients in the laparoscopic group required significantly less parenteral analgesics than those who underwent open repair, and the visual analog pain scores in days 1 and 3 after surgery were significantly lower in the laparoscopic group as well. Laparoscopic repair required significantly less time to complete than open repair. The median postoperative stay was 6 days in the laparoscopic group versus 7 days in the open group. There were fewer chest infections in the laparoscopic group. There were two intraabdominal collections in the laparoscopic group. One patient in the laparoscopic group and three patients in the open group died after surgery. CONCLUSIONS Laparoscopic repair of perforated peptic ulcer is a safe and reliable procedure. It was associated with a shorter operating time, less postoperative pain, reduced chest complications, a shorter postoperative hospital stay, and earlier return to normal daily activities than the conventional open repair.
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Affiliation(s)
- Wing T Siu
- Department of Surgery, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong, SAR, China.
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Hashiba K, Carvalho AM, Diniz G, Barbosa de Aridrade N, Guedes CA, Siqueira Filho L, Lima CA, Coehlo HE, de Oliveira RA, Carvaiho AM, Coetho HE. Experimental endoscopic repair of gastric perforations with an omental patch and clips. Gastrointest Endosc 2001; 54:500-4. [PMID: 11577318 DOI: 10.1067/mge.2001.118444] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The omental patch is a standard surgical treatment of gastroduodenal ulcer perforation. This is a report of an experimental method for endoscopic repair of anterior gastric perforations with an omental patch developed by using a porcine model. METHODS A standardized gastric perforation was created in 10 pigs. The omentum was pulled into the gastric lumen and fixed endoscopically to the muscularis propria layer of the stomach with metallic clips. RESULTS The postoperative course was normal in 9 animals. An ulcer was evident at the site of repair at follow-up endoscopy. At autopsy, the omentum was adherent to the external side of gastric wall. One animal died with peritonitis, presumably because the muscularis propria layer could not be seen during the procedure, and the clips attached the omentum only to the mucosa. CONCLUSIONS Endoscopic repair with an omental patch appears to be an effective procedure for closure of gastric perforations.
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Affiliation(s)
- K Hashiba
- Faculdade de Medicina, Universidade Federal de Uberlândia Minas Gerais--Hospital Sírio Libanês, São Paulo, Brazil
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