Combined conservative management and percutaneous peritoneal drainage as damage control approach in high-risk patients with perforated peptic ulcers

Abstract

High risk patients with perforated peptic ulcer, where both the surgeon and anaesthetist are hesitant to operate, were managed by combined conservative management and bilateral percutaneous peritoneal drainage under local anaesthesia as a damage control approach; followed by either definitive surgery or omental patch closure. Here we study the management outcome in terms of morbidity & mortality of such patients.A prospective study of 60 patients presenting to VSSIMSAR, Burla was done between Feb 2018 and Jan 2020. Study population includes patients with perforated peptic ulcer confirmed by pneumo-peritoneum in X-ray and bilious peritoneal tap; with high peri-operative risk (PULP score 8-18). They were managed by combined conservative management and bilateral percutaneous peritoneal drainage under local anaesthesia. The outcome in terms of improved general condition and definitive/ omental patch closure, morbidity and mortality rates were noted. After risk stratification according to PULP score, total number of high-riskcases (PULP score >8) were 60 (male-39, female-21); Majority of them were elderly (90%). Most common complication was ARDS (28.3%). Maximum number of patients (75%) were improved by the damage control approach without significant complications and offered exploratory laparotomy & needful. Localised abscess were observed in around 13.33% patients; which were managed by image guided aspiration under antibiotic coverage. The overall mortality rate was 11.67%. Combined conservative management and percutaneous peritoneal drainage as damage control, which can be done in resource limited centre; followed by either definitive surgery or omental patch closure is associated with reduced mortality.