The Applicability of Laparoscopic Gastrectomy in the Surgical Treatment of Giant Duodenal Ulcer Perforation

Analysis of prognostic factors for postoperative complications and mortality in elderly patients undergoing emergency surgery for intestinal perforation or irreversible intestinal ischemia

Purpose

Because the global geriatric population continues to increase, the assessment of emergency surgical outcomes in elderly patients with acute peritonitis will become more important.

Methods

A retrospective review was conducted on the data of 174 elderly patients who underwent emergency surgery for intestinal perforation or intestinal infarction between June 2010 and November 2022. We conducted an analysis of the risk factors associated with postoperative complications and mortality by evaluating the characteristics of patients and their surgical outcomes.

Results

In our study, most patients (94.3%) had preexisting comorbidities, and many patients (84.5%) required transfer to the intensive care unit following emergency surgery. Postoperative complications were observed in 84 individuals (48.3%), with postoperative mortality occurring in 29 (16.7%). Multivariate analysis revealed preoperative acute renal injury, hypoalbuminemia, and postoperative ventilator support as significant predictors of postoperative mortality.

Conclusion

When elderly patients undergo emergency surgery for intestinal perforation or infarction, it is important to recognize that those with preoperative acute renal injury, hypoalbuminemia, and a need for postoperative ventilator support have a poor prognosis. Therefore, these patients require intensive care from the early stages of treatment.

Iatrogenic Duodenal Perforation After Surgery: a Systematic Review

Duodenal perforation consequent to prior surgery is a rare but severe complication carrying serious consequences if not promptly managed. This study aims to identify the best treatment pathway available to date. This is a systematic review registered to PROSPERO. The literature research was conducted on Ovid Medline, Embase, and Cochrane up to February 2022 to identify all papers reporting surgical-related duodenal perforations. Twelve articles were included. Most of these studies were case reports or case series. The most common cause of perforation was laparoscopic cholecystectomy (72.7%). The median time to symptom appearance was 2 days. Most of these perforations were severe injuries located in the first portion of the duodenum. Only one patient was treated with a non-interventional conservative management, which failed. Five patients were managed with interventional non-surgical treatments: 4 with endoscopy (50% failure) and one with a percutaneous occluder. Different surgical treatments were reported: direct suture (100% failure), direct suture and T-tube duodenostomy (75% failure), simple abdominal drainage, and suture with pyloric exclusion. Further extensive surgeries were also reported. The overall mortality rate was 13.6%, with a median hospital stay of 38.5 days. This review shows a wide spectrum of managements for patients with duodenal perforation related to prior surgery. The decision on which treatment to adopt must consider patient’s clinical setting and duodenal defect characteristics (size, site, and time to diagnosis). A tentative treatment flowchart is provided, although larger sample size studies are needed to obtain a treatment pathway based on evidence.

Duodenal ulcer perforation: A systematic literature review and narrative description of surgical techniques used to treat large duodenal defects

BACKGROUND

There is no consensus on optimal surgical treatment of large duodenal defects arising from perforated ulcers, even though such defects are challenging to repair and inadequate repair is associated with high morbidity and mortality. The aim of this study was to carry out a systematic literature review of different surgical techniques used to treat large duodenal perforations, provide a narrative description of these techniques, and propose a framework for approaching this pathology.

METHODS

PubMed/MEDLINE database was searched for articles published in English between January 1, 1970, and December 1, 2020. Studies describing surgical techniques used to treat giant duodenal ulcer perforation and their outcomes in adult patients were included. No quantitative analysis was planned because of the heterogeneity across studies.

RESULTS

Out of 960 identified records, 25 studies were eligible for inclusion. Two randomized controlled trials, one case-control trial, three cohort studies, 14 case series, and 5 case reports were included. Eight main surgical approaches are described, ranging from simple damage-control operations, such as the omental plug and triple-tube techniques, all the way to complex resections, such as gastrectomy.

CONCLUSION

Evidence on surgical treatment of large duodenal defects is of poor quality, with the majority of studies corresponding to Oxford levels 3b-4. Current evidence does not support any single surgical technique as superior in terms of morbidity or mortality, but choice of technique should be guided by several factors including location of the perforation, degree of duodenal tissue loss, hemodynamic stability of the patient, as well as expertise of the operating surgeon.

LEVEL OF EVIDENCE

SR with more than two negative criteria, Level IV.

Outcomes of laparoscopic primary gastrectomy with curative intent for gastric perforation: experience from a single surgeon

BACKGROUND

Gastric cancer perforation is rare and difficult to distinguish from gastric ulcer perforation before surgery. Peritonitis caused by gastric perforation requires emergency surgery. The optimal surgical strategy for gastric perforation has not been established.

MATERIAL AND METHODS

Data from 43 patients who underwent primary gastrectomy with curative intent for gastric perforation between June 2010 and November 2019 were reviewed. Patients were classified into gastric ulcer and gastric cancer groups. Early surgical outcomes and overall survival were assessed.

RESULTS

There were no significant differences in clinical characteristics between the two groups except regarding preoperative shock. Laparoscopic gastrectomy was performed in 35 of 43 patients. There were no conversions to open surgery. The surgical findings demonstrated that the gastric cancer group had larger mass lesions with significantly larger perforations than did the gastric ulcer group. There were no significant differences in early surgical outcomes. Severe postoperative complications occurred in nine patients, five of whom died within one month of surgery. The majority of patients (90%) had stage III or IV gastric cancer. The 5-year survival rate was 19.5%.

CONCLUSION

We found no definitive differences in clinical characteristics distinguishing gastric cancer from ulcers. Considering our surgical outcomes, laparoscopic primary gastrectomy performed by an expert is a useful technique for emergency gastric perforation. However, unless an expert is available, caution should be used when selecting laparoscopic primary gastrectomy with curative intent as a surgical method.

Extending the Indication for Laparoscopic Surgery in Patients With Pan-Peritonitis

BACKGROUND

There have been reports of favorable results in patients with peritonitis who underwent laparoscopic surgery. The present study evaluated the outcomes of laparoscopic surgery in patients with pan-peritonitis.

MATERIALS AND METHODS

We enrolled 148 patients who underwent open and laparoscopic surgery for pan-peritonitis between January 2015 and December 2017 at Hanyang University Guri Hospital. Patients with appendicitis or cholecystitis were excluded from this study because of the simplicity of the technique and the favorable postoperative prognosis. Surgical outcomes including open conversion, morbidity, mortality, risk, and prognostic factors were evaluated.

RESULTS

During the study period, 125 patients (84.5%) underwent laparoscopic surgery. The conversion to open surgery occurred in 7 (5.3%) patients. In the laparoscopic surgery group, 27 patients (21.6%) experienced postoperative complications, and 6 died (4.8%). Multivariate analysis showed that age of older than 75 years was a risk factor for postoperative complications. Especially, preoperative shock (<90 mm Hg) and a longer time from symptom onset (over 2 d) to surgery were prognostic factors for postoperative mortality.

CONCLUSIONS

On the basis of our results and experiences, we believe that laparoscopic surgery is applicable to surgery of pan-peritonitis. And, preoperative shock and longer time from onset are prognostic factors of mortality in laparoscopic group. Therefore, we are confident that careful patient selection and specialized laparoscopic team should be considered in order to have best results.

Laparoscopic primary repair with omentopexy for duodenal ulcer perforation: a single institution experience of 21 cases

PURPOSE

Despite the great advances in laparoscopic techniques, most active general surgeons do not apply laparoscopic surgery in the treatment of duodenal ulcer perforation when facing a real-life emergency. Therefore, our study was designed to evaluate the feasibility of laparoscopic surgery in duodenal ulcer perforation, and provide a step-by-step protocol with tips and recommendations for less experienced surgeons.

MATERIALS AND METHODS

Between March, 2011 and May, 2012, 21 patients presenting with duodenal ulcer perforation underwent laparoscopic primary repair with omentopexy. There were no contraindications to perform laparoscopic surgery, and the choice of primary repair was decided according to the size of the perforation. The procedure for laparoscopic primary repair with omentopexy consisted of peritoneal lavage, primary suture, and omentopexy using a knot pusher.

RESULTS

During the operation, no conversion to open surgery or intra-operative events occurred. The median operation time was 45.0 minutes (20~80 minutes). Median day of commencement of a soft diet was day 6 (4~17 days). After surgery, the median hospital stay was 8.0 days (5~27 days). Postoperative complications occurred in one patient, which included a minor leakage. This complication was resolved by conservative management.

CONCLUSIONS

Although our study was carried out on a small number of patients at a single institution, we conclude that laparoscopic primary repair can be an effective surgical method in the treatment of duodenal ulcer perforation. We believe that the detailed explanation of our procedure will help beginners to perform laparoscopic primary repair more easily.