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

Outcomes of laparoscopic modified Cellan-Jones repair versus open repair for perforated peptic ulcer at a community hospital

INTRODUCTION

Minimally invasive or open Graham Patch repair remains the gold standard approach for management of perforated peptic ulcers (PPU). Herein, we report outcomes of laparoscopic technique and compare it with open approach at a community hospital.

METHODS

Retrospective observational study conducted comparing laparoscopic modified Cellan-Jones repair (mCJR) versus the standard open repair of PPU. Patients aged 18-90 years during 2016-2021 were offered either a minimally invasive or open approach depending on surgeon laparoscopic capability, and were compared in terms of demographics, co-morbidities, intra-operative details, and short-term outcomes.

RESULTS

A total of 49 patients were included (46.9% males, mean age 52.9 years, mean BMI 25.0, ASA ≥ III 75.5%, 75.5% smokers, 26.5% current NSAIDs use, and 71.4% alcohol drinkers). Duodenum was the most common perforation site (57.1%), and majority of ulcers were 1-2 cm (72.9%). Laparoscopic approach was performed in 16 consecutive patients (32.7%) by a single surgeon, with no conversions. Preoperative characteristics were similar for both groups. Compared to open approach, laparoscopic group were taken to operation immediately (< 4 h) (87.5% vs. 15.2%, p < 0.001), had lower estimated blood loss (11.8 ml vs. 73.8 ml, p = 0.063), and longer operative time (117.1 min vs. 85.6 min, p = 0.010). Postoperatively, nasogastric tube was removed earlier in laparoscopic group (POD1-2, 87.5% vs. 24.2%, p = 0.001), with earlier resumption of diet (POD1-2, 62.6% vs. 9.1%, p = 0.002), less narcotic usage (< 3 days, 58.3% vs. 6.1%, p < 0.001), earlier return of bowel function (POD1-2, 43.8% vs. 9.1%, p = 0.003) and shorter length of stay (LOS) (3.7 days vs. 16.1 days, p < 0.001). Both in-house mortality and morbidity rates were lower in the laparoscopic group, but not statistically significant [(0% vs. 6.1%, p = 0.347) and (12.5% vs. 39.4%, p = 0.500), respectively].

CONCLUSION

Laparoscopic mCJR is a feasible method for repair of PPU, and it is associated with shorter LOS, and less narcotics usage in comparison to the open repair approach.

A case of posterior duodenal perforation: Diagnosis and treatment strategy

BACKGROUND

Posterior duodenal perforation is a clinically rare entity with a very poor prognosis. Because of its atypical clinical manifestations, posterior duodenal perforation is prone to misdiagnosis or missed diagnosis.

CASE SUMMARY

We report a patient who was diagnosed with posterior duodenal perforation. After operation, nutritional support, and anti-infective treatment, the patient was cured and discharged.

CONCLUSION

In addition to the bulb, the rest of the duodenum is located in the retroperitoneum, so the digestive juice overflows to the retroperitoneum during the perforation of the posterior wall, which leads to the atypical clinical symptoms and signs. For patients with acute abdominal pain, it is recommended to conduct whole abdominal CT examination as soon as possible to make a clear diagnosis. For patients with a perforated duodenal wall, operation should be performed as soon as possible. Attention should be paid to the prevention and treatment of duodenal fistula. Hassan three tube decompression method is widely used, and this procedure should follow the principle of injury control and should be actively adopted in this kind of emergency.

Single-Port Laparoscopic Repair of Perforated Duodenal Ulcers

BACKGROUND

Laparoscopic single-port surgery has widely been introduced for the treatment of various abdominal conditions. But controversies still exist regarding its potential advantages and risks, especially for emergency surgery. The aim of this study was to evaluate the results of a single-port laparoscopic repair using straight laparoscopic instruments for the treatment of perforated duodenal ulcers.

METHODS

A prospective consecutive case series was conducted including all patients with a perforated duodenal ulcer who underwent a laparoscopic single-port repair at a single institution from January 2012 to June 2018. The operation was performed through a single port using conventional straight laparoscopic instruments and intra-corporeal knot tying techniques.

RESULTS

Out of 75 patients, simple closure of the perforation without omental patch was accomplished in 96% of cases. Conversion to an open operation was required in one patient (1.3%) due to a posterior duodenal perforation, and additional trocar placement was needed in another patient (1.3%). The mean incision length was 2.0 ± 0.2 cm. The mean operation time was 63.0 ± 26.6 min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8 days. Mean duration of analgesic use was 2.8 ± 0.8 days. The rate of postoperative complications was 2.7%, including two patients with wound infections. There were no instances of intestinal leak or abscess. The postoperative hospital stay was 5.7 ± 1.2 days.

CONCLUSION

Laparoscopic single-port repair using conventional straight laparoscopic instruments with intra-corporeal knot tying technique was safe and feasible for patients with perforated duodenal ulcers with low risk factors. This method offers results comparable to those expected with the standard multiport laparoscopic approach with the addition of improved cosmetic outcomes.

Endoscopic stent treatment of a duodenal ulcer perforation using a semi-covered stent

Placement of a covered self-expandable metal stent when primary surgery had failed to close the duodenal ulcer perforation or as a primary modality is a promising procedure when compared to other currently available types of surgical rescue or intervention.

Laparoscopic pyloroplasty for perforated peptic ulcer

Peptic ulcer is a common disease affecting millions of people every year. Despite improved understanding and treatment of the disease, the number of patients admitted with duodenal peptic ulcer perforation has not decreased. Deaths from peptic ulcer disease overcome other common emergency situations. Laparoscopic repair of the perforated peptic ulcer (PPU) is the gold standard approach for simple perforation. However, in patients with large perforated chronic ulcers laparotomy with pyloroplasty is the standard treatment. It is generally accepted to perform open surgery in PPU emergencies because of the greater knowledge and experience gathered over the past decades and less potential harm for the patient or surgical complications. We present a case of successful laparoscopic pyloroplasty of a perforated duodenal ulcer with stenosis.