Management Of Perforated Duodenal Ulcer Research Articles

The Application of Enhanced Recovery After Surgery Protocols in Patients With Perforated Duodenal Ulcer.

Background Enhanced recovery after surgery (ERAS) protocols are nowadays considered the standard of care for various elective surgical procedures. However, its utilization remains low in tier-two and tier-three cities of India, and there exists a significant variation in the practice. In the present study, we have investigated thesafety and feasibility of these protocols or pathways in emergency surgery for perforated duodenal ulcer disease. Methods A total of 41 patients with perforated duodenal ulcers were randomly divided into two groups. All the patients across the study were treated surgically with the open Graham patch repair technique. Patients in group A were managed with ERAS protocols, while patients in group B were managed with conventional peri-operative practices. A comparison was established between the two groups in terms of the duration of hospital stay and other postoperative parameters. Results The study was conducted on 41 patients who presented during the study period. Group A patients (n=19) were managed with standard protocols, and group B patients (n=22) were managed with conventional standard protocols. As compared to the standard care group, patients in the ERAS group showed quicker postoperative recovery and lesser complications. The need for nasogastric (NG) tubereinsertion, postoperative pain, postoperative ileus, and surgical site infections (SSI) were all significantly lower in the patients of the ERAS group. A significant reduction in the length of hospital stay (LOHS) was found in the ERAS group when compared to the standard care group (relative risk {RR}=61.2; p=0.000). Conclusions The application of ERAS protocols with certain modifications in the management of perforated duodenal ulcers yields significant outcomes in terms of reduced duration of hospital stay and fewer postoperative complications in a selected subgroup of patients. However, the application of ERAS pathways in an emergency setup needs to be further evaluated to develop standardized protocols for a surgical emergency group of patients.

Management of perforated duodenal ulcer at a tertiary care hospital

Introduction: Multiple etiologies are associated with duodenal perforations such as peptic ulcer disease, iatrogenic causes and trauma. Computed tomography with intravenous and oral contrast is the most valuable imaging technique to identify duodenal perforation. In some cases, surgical exploration may be necessary for diagnosis. Materials and Methods: The case files of all the patients were retrospectively ana- lyzed for patient particulars, intra-operative findings, surgery performed, post-operative stay, morbidity and mortality. The groups were then compared with each other in terms of age, leak rates, hospital stay, morbidity, mortality and the surgery performed. Statistical analysis was done using the chi-square and the t- test by an inde- pendent comparison of each group singly against another by a statistician who was blinded to the study. A p value of < 0.05 was taken as significant. Results: The majority of patients came under the ‘small’ perforation group, but there were 38 patients (23.46 %) with large perforations as per our definition. These patients had a higher age of presentation (47.18 years) than the patients with smaller perforations (39.46 years). Giant perforations, or perforations greater than 3 cms in size were seen only 2 cases, accounting for a small percentage (1.28 %) of all cases seen. Conclusion: The type of treatment should be individualized and depends on the mechanism of injury, the timing, location and extent of the injury and the clinical state of the patient.

Pedicled Tubular Omental Patch for Tamponade of Transfixing Gunshot Bilobar Liver Injury: A Case Report

Introduction: Liver injuries are frequent in abdominal trauma and may be managed using a variety of methods. The operative management of deep, penetrating wounds generally involves balloon tamponade of the wound tract using a Sengstaken-Blakemore catheter. Case Presentation: A haemodynamically unstable 34-year-old male with multiple thoracoabdominal gunshot wounds was transferred to the operating theatre. At laparotomy, a grade 3 transfixing (through and through) bilobar hepatic wound was discovered with active hemorrhage. Unfortunately, no suitable balloon catheters were available, so, as an alternative, tamponade of the wound tract was successfully achieved using a tubular omental patch. Discussion: Omental patches are commonly used in the management of perforated duodenal ulcers and have been used to prevent recurrence following hepatic cyst de-roofing. To the authors’ knowledge, this is the first description of this technique for the management of penetrating bilobar transfixing hepatic injury. Conclusion: A tubular omental patch may be used to achieve tamponade of deep wounds in penetrating hepatic trauma. This could be a particularly useful technique in resource-poor environments, or where a suitable balloon catheter is otherwise unavailable.

Laparoscopic Single Figure of Eight Suturing Omentopexy for the Treatment of a Perforated Duodenal Ulcer

PurposeSafe and effective surgical treatment of peptic ulcer perforations is fundamental to achieve favorable outcomes. We present laparoscopic single figure of eight suturing omentopexy for perforated duodenal ulcer and review associated clinical outcomes. This is a new formulaic surgical technique for laparoscopic omentopexy.MethodsLaparoscopic single figure of eight suturing omentopexies for perforated duodenal ulcer were completed in 15 consecutive patients between April 2008 and November 2017 at Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea. Using prospectively collected data, we performed an observational study on an intention-to-treat basis.ResultsThe mean age of the 15 patients who underwent laparoscopic repair was 41.7±13.9 years. The perforation site was the anterior duodenal bulb in all patients. The median perforation size was 5 mm (range: 3~8 mm). The mean operation time was 66.7±19.6 minutes. There was no evidence of leakage from the omentopexy site clinically or in the postoperative upper gastrointestinal series. One patient (6.7%) experienced the postoperative complication of pneumothorax. There were no cases of postoperative mortality or reoperation within 30 days after surgery. The median time to tolerance of regular diet was 6 (range: 4~9) days. The median postoperative hospital stay was 7 days (range: 5~11 days).ConclusionLaparoscopic single figure of eight suturing omentopexy can be a viable option in the surgical management of perforated duodenal ulcer in selected patients without surgical risk factors. Laparoscopic single figure of eight suturing omentopexy is safe and easy to perform, and may therefore reduce operation time.

Study of Laparoscopic Repair Versus Laparotomy In Management of Peptic Perforation Peritonitis

Introduction: Despite the widespread use of antisecretory agents and eradication therapy, the incidence of perforated peptic ulcer has changed little. Since the initial reports of successful laparoscopic management of perforated duodenal ulcers and perforation peritonitis several larger comparative series have been published confirming the technical feasibility and advantages of laparoscopic approach. Objectives: The aim is to compare the outcome and efficacy of laparoscopic repair with conventional laparotomy in the management of peptic perforation. Methods: The study was conducted on patients with diagnosis of peptic perforation in Hi-tech medical college and hospital, Bhubaneswar. It is a retrospective and prospective study from September 2012 to April 2014. Result: 50 patients of peroration peritonitis were operated randomly by laparoscopic repair and laparotomy. It was found that the laparoscopic repair of perforated peptic ulcer was associated with less intra operative blood loss, no intra operative complications, minimum post operative complications, minimum postoperative pain which was significant as compared to laparotomy repair. Conclusion: Laparoscopic repair of perforated peptic ulcer could be considered as a treatment option in routine clinical practice in the management of peptic perforation peritonitis.

A review of the management of perforated duodenal ulcers at a tertiary hospital in south western Nigeria.

Gastro-duodenal perforations are common and may complicate peptic ulcer disease. Management is often by surgical closure. To determine the patterns of presentation and mode of management of duodenal ulcer perforations. Retrospective review of patients with duodenal ulcer perforations seen at the Obafemi Awolowo University Teaching Hospital between June 2001 and July 2011. Patients' records were reviewed for demography, duration of disease, probable risk factors, type of surgery and complications. Data obtained was analyzed using SPSS 15.0. Forty- five patients were reviewed. There were 37 males (82.2%). Mean age was 39.7years (range 15-78years). There were 10 (22.6%) students and 8(17.8%) farmers. NSAIDs abuse (11), previous peptic ulcer disease (2), and no prior dyspeptic symptoms (20) constituted 24.4%, 4.4% and 44.4% respectively of cases. Seven (16%) patients presented less than 24 hours of onset of illness. Forty one perforations (91.1%) involved the first part of duodenum. Twenty two (49%) patients had Graham's omental patch. We had one (2.2%) failed repair and six (13.3%) mortalities. Late presentation of duodenal ulcer perforation is common with high mortality. Pragmatic surgical intervention with Graham's omentopexy with broad spectrum antibiotics is still commonly practiced.

Laparoscopic versus open management of duodenal perforation: a comparative study at a District General Hospital.

IntroductionDuodenal perforation is one of the common pathologies in patients presenting in emergency with acute abdominal pain in an emergency ward and requires prompt surgery as life saving and curative intervention. The present study was conducted to determine whether the minimal access approach by laparoscopy was equally feasible as the open method.AimTo compare laparoscopic vs. open management duodenal perforation in all aspects.Material and methodsInclusion criteria: patients presenting to the emergency ward with acute pain in the abdomen with clinical signs of peritonitis and air under the diaphragm on X-ray abdomen standing were selected. Exclusion criteria were: patient age < 15 years and > 70 years, presentation > 2 days, shock with systolic blood pressure < 90 mm Hg which did not improve after hydration with 2000 ml of Ringer lactate solution, respiratory distress, history of cardiac disorder or respiratory disorders such as ischemic heart disease, arrhythmias, chronic obstructive pulmonary disease or asthma, bleeding and clotting disorders, pregnancy in females, previous upper abdominal surgery, and intra-operatively patients having perforation other than duodenal perforation. After excluding patients fitting the above criteria, two groups – test and control – were formed.ResultsWe found that complications both early and late were significantly fewer in patients treated by laparoscopy. Thus laparoscopy was both feasible and had comparable mortality and leakage rate.ConclusionsLaparoscopic management of perforated duodenal ulcer is feasible, effective and decreases morbidity and overall treatment time and cost if performed in properly selected patients.

Mortality in perforated duodenal ulcer depends upon pre-operative risk: a retrospective 10-year study

Most patients presenting with acutely perforated duodenal ulcer undergo operation, but conservative treatment may be indicated when an ulcer has spontaneously sealed with minimal/localised peritoneal irritation or when the patient's premorbid performance status is poor. We retrospectively reviewed our experience with operative and conservative management of perforated duodenal ulcers over a 10-year period and analysed outcome according to American Society of Anesthesiologists (ASA) score. The records of all patients presenting with perforated duodenal ulcer to the Department of Surgery, Mayo General Hospital, between January 1998 and December 2007 were reviewed. Age, gender, co-morbidity, ASA-score, clinical presentation, mode of management, operative procedures, morbidity and mortality were considered. Of 76 patients included, 48 (44 operative, 4 conservative) were ASA I-III, with no mortality irrespective of treatment. Amongst 28 patients with ASA-score IV/V, mortality was 54.5% (6/11) following operative management and 52.9% (9/17) with conservative management. In patients with a perforated duodenal ulcer and ASA-score I-III, postoperative outcome is uniformly favourable. We recommend these patients have repair with peritoneal lavage performed, routinely followed postoperatively by empirical triple therapy. Given that mortality is equivalent between ASA IV/V patients whether managed operatively or conservatively, we suggest that both management options are equally justifiable.

Conservative management of perforated duodenal ulcer.

42 malades atteints d'ulcere duodenal perfore sont traites sans chirurgie: analgesie par voie veineuse, antibiotiques, rehydratation, et surtout tubage gastrique pour aspiration et drainage repetes, avec verification frequente de la bonne position du catheter a l'extremite de la grande courbure. Le traitement est efficace dans 34 cas, en 4 jours en moyenne. Les 8 autres malades doivent etre operes

NON-OPERATIVE TREATMENT FOR PERFORATED DUODENAL ULCER

The aim of this study is to review our recent experience with selective non-operative management of perforated duodenal ulcers (PDU). The patients included in this study had PDU treated non-operatively between 1995–2002. The protocol for the management of PDU has been developed based on experience at our department. Our policy of the selective treatment for PDU was that patients over 65 years old had immediate laparoscopic omental patch repair (LOPR) and the other was selected non-operative management. Non-operative management consisted of intravenous fluids, broad-spectrum antibiotics, nasogastric tube suction (occasionally) ultrasound guided percutaneous drainage of intraperitoneal fluids (occasionally) and H2 blockers. All patients had emergency endoscopies before treatments and were made diagnoses of PDU. If evidence of peritonitis progressed, or if there was not evidence of regression by 24–48 hours, laparoscopic surgery was indicated. Endosopic examination was performed on about 4–5th day, and if the perforation sealing was confirmed, oral diet resumption was then started. Helicobacter pylori (HP) status was checked after discharge. One hundred twenty-six PDU patients were evaluated. The patients ranged in age from 17 to 99 years old, with a mean age of 49 years. Males predominated in a ratio of 4:1. Ninety-nine (79%) of the 126 cases with PDU had non-operative treatment. There were 85 men and 14 women. Non-operative treatment was abandoned in 9 cases (9%) due to deteriorating peritonitis and converted to laparoscopic interventions. Mean hospital stay for the 27 patients treated operatively was 30+-22 days; the mean hospital day of the 99 patients primarily treated non-operatively was 20+-11 days. Re-perforation did not occur. The overall mortality rate was 7%. The mortality rate for the patients treated operatively was 26%; the mortality of the patients primarily treated non-operatively was 2%. The1death in this latter group occurred in a man with cardiopulmonary arrest on arrival and the other death occurred in a man with chronic pulmonary failure. Overall positive rate of IgG and HP status was 73 and 56%, respectively. Non-operative management for the relatively younger patients with PDU can be safely performed. We emphasize in our study the labour intensive process that is required to achieve acceptable results.

Management of perforated duodenal ulcer in a resource poor environment.

The majority of literature on the management of perforated duodenal ulcer comes from the west. However, this is not necessarily appropriate in the developing world where perforated ulcers occur in younger patients, there is a strong association with cigarette smoking, and presentation is often delayed. An attempt to guide management of perforated duodenal ulcer in the developing world using the best evidence available. Review of the literature on perforated ulcers and retrospective chart review of cases from a rural African hospital. Relevant studies from the western and developing world literature. Med-line search. Assessment of relevance to clinical management of perforated duodenal ulcers in the developing world. Due to recognition of Helicobacter pylori (HP) as a causative agent in duodenal ulcer disease many western surgeons are questioning the need for definitive ulcer surgery in the acute management of perforated duodenal ulceration. This philosophy may not be appropriate in the developing world due to poor HP eradication rates, conditions fostering re-infection with HP, problems with patient compliance in taking medications, and difficulties with follow-up. It is suggested that selected patients, without preoperative risk factors, are offered definitive surgery but those at any risk of postoperative mortality be treated with conservative surgery and treatment for HP. These patients will have to be followed closely to check ulcer healing. Attention will also need to be paid to stopping smoking.

Non-operative management of perforated duodenal ulcer.

We describe the selective non-operative management of 34 patients who had an initial diagnosis of perforated duodenal ulcer made on acute presentation between 1984-1994 in our district surgical unit. Diagnosis of the condition was made on clinical grounds with the aid of an erect chest X-ray which demonstrated pneumoperitoneum in 28 patients (82 per cent). Six patients (18 per cent) who did not respond to non-operative treatment required surgical intervention; 3 patients had an unsealed duodenal ulcer perforation; 2 had a perforated benign gastric ulcer and 1 patient had acute gangrenous cholecystitis. The overall mortality and morbidity rate was 3 per cent and 35 per cent respectively. There were no documented reperforations over a mean follow-up period of 27 months. While these figures are acceptable and comparable with operative intervention for this condition, we do however stress the labour intensive methods and close clinical monitoring that is required to avoid morbid sequelae.

Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients.

Laparoscopic management of perforated duodenal ulcers is safe and effective. Prospective nonrandomized controlled trial. Tertiary care academic center. Between October 1993 and October 1997, 30 patients underwent laparoscopic Graham patch repair of perforated duodenal ulcers and 16 had an open repair. Morbidity, operating time, analgesic requirements, length of hospital stay, and time to return to work. There was no difference in morbidity between the 2 groups. Operating time was longer in the laparoscopy group (106 vs. 63 minutes; P = .001). Patients with shock on admission or symptoms for more than 24 hours had a higher conversion rate (P<.05). The laparoscopy group required fewer analgesics, had a shorter stay, and a quicker recovery. Laparoscopic repair for perforated ulcers is safe and maintains benefits of the minimally invasive approach. Laparoscopy is not beneficial in patients with shock.

Management of perforated duodenal ulcers

Management of perforated duodenal ulcers