Crack cocaine-related prepyloric perforation treated laparoscopically

Abstract

Perforation, which occurs in seven to 10 patients per 100,000 population annually, complicates 5-10% of peptic ulcers. Crack cocaine has been associated with many gastrointestinal disorders, including ulcer perforation. Crack-related gastroduodenal perforations, typically prepyloric, have been on the rise in the last decade. Suggested mechanisms include ischemia, motility disorders, increased air swallowing, platelet-related thrombosis, and increased ACTH and corticosterone secretion. A 28-year-old man presented with vomiting and sudden generalized abdominal pain 3 h after smoking a "rock" (a 100-mg cube of crack). Physical examination revealed generalized guarding, and plain films showed free intraperitoneal air. Laparoscopy confirmed the diagnosis of generalized peritonitis secondary to a 5-mm perforation of the prepyloric anterior wall of the gastric antrum. Omentum-patched primary closure and thorough abdominal irrigation were undertaken. The postoperative course was uneventful. Omeprazole and anti-H. pylori treatment, including erythromycin and metronidazole, were maintained for 8 weeks and 1 week, respectively. Although drug addicts are not easily compliant with long-term medical treatment, in the particular case of crack addiction, the vasoconstrictive and dismotility effects of cocaine may precipitate gastric necrosis and paralysis, respectively, in the case of vagotomy. Although distal gastrectomy was the wisest choice when open ulcer surgery was adopted, the laparoscopic treatment of perforated ulcer, with either suture or sutureless techniques, has been found to be comparable to open surgery with regard to postoperative morbidity, reoperation rates, and mortality. The potential advantages of laparoscopy include the avoidance of large incisions, less attendant pulmonary morbidity, less wound infection, and possibly fewer postoperative adhesions.