Treatment Of Perforated Duodenal Ulcer Research Articles

Outcome of Laparoscopic Repair of Duodenal Ulcer Perforation Compared with Open Technique

Background: The surgical treatment of perforated duodenal ulcers is not controversial; however, the best surgical strategy is still up for debate. The perforation closure with an omental patch or without it during surgery is the basis of perforated duodenal ulcers treatment. Laparoscopic surgery can now be used to repair a perforated duodenal ulcer due to developments in minimal access surgery. Aim: In this analysis, the results of open versus laparoscopic repair of perforated duodenal ulcers were compared in terms of operating time, length of hospital stays, postoperative pain and complications after the operation, among other factors. Methods: This prospective comparative study was held at the surgical department of Agha Khan University Hospital, Karachi for one-year duration from January 2022 to December 2022. Patients were divided randomly into two groups, A and B, who underwent operations using laparoscopic and conventional methods, correspondingly, and results were compared. Results: This study found that men between the ages of 51 and 60 were most frequently affected. Laparoscopic group patients experienced much less post-operative pain, need less analgesics, minimum wound infection, and less stay in hospital than open group patients (p 0.05). Conclusions: Laparoscopic repair when performed on carefully chosen patients for perforated duodenal ulcers, it is safe, practical, and produces better outcomes than open surgery. Keywords: Omental patch, laparoscopic repair, open repair, perforated duodenal ulcer

Місце малоінвазивних технологій при хірургічному лікуванні перфоративної виразки дванадцятипалої кишки

Мета роботи. Оцінити ефективність та доцільність застосування малоінвазивних технологій при хірургічному лікуванні перфоративної виразки дванадцятипалої кишки. Матеріали та методи. У роботі проаналізовані результати діагностики та лікування 124 пацієнтів із перфоративною виразкою дванадцятипалої кишки, які були госпіталізовані в ургентному порядку та перебували на лікуванні у хірургічних клініках Київської міської клінічної лікарні швидкої медичної допомоги в 2016 році. У хворих другої (36 пацієнтів) групи на відміну від першої (88 пацієнтів) групи було розширено показання до застосування малоінвазивних технологій. Клініко-діагностичний алгоритм включав лабораторні, інструментальні та біохімічні методи дослідження, а також статистичні методи дослідження. Результати. Результати аналізу діагностики та лікування пацієнтів із перфоративною виразкою дванадцятипалої кишки виявили суттєве превалювання хворих віком від 20 до 40 років чоловічої статі, і лише кожен дванадцятий пацієнт був похилого чи старечого віку. Переважна більшість хворих (64,18 %) госпіталізувалася протягом перших шести годин з моменту перфорації виразки, у більшості пацієнтів (76,24 %) перебіг перитоніту за Mannheim Peritonitis Index досягав 21 бала. Комплексне застосування інструментальних методів дозволило встановити першопричину захворювання в 111 (89,52 %) випадках, а їх недооцінка чи тяжкість перебігу перитоніту стала підставою до інтраопераційного встановлення діагнозу в 11 (10,48 %) пацієнтів. Розширення показань до застосування малоінвазивних технологій у пацієнтів другої групи на відміну від першої групи дозволило у половини хворих виконати лапароскопічну дуоденографію, у 5 (13,89 %) пацієнтів — лапароскопічну дуоденопластику та у 2 (5,56 %) хворих — лапароскопічно-асистовану дуоденопластику. Це супроводжувалось зменшенням регіонарних ускладнень на 3,66 %, системних ускладнень — на 4,67 %, летальності — на 1,14 %, також суттєво скорочувався термін післяопераційної реабілітації та соціальної адаптації. Висновки. Проведення інструментальної верифікації перфоративної виразки дванадцятипалої кишки дозволило при застосуванні лише первинної рентгеноскопії виявити перфорацію у 70 (58,06 %) хворих, але відсутність її рентгенологічних ознак при недотриманні всього діагностичного комплексу у кожного десятого пацієнта призвела до інтраопераційного встановлення діагнозу. Застосування невідкладної лапароскопії у хворих другої групи з перфоративною виразкою дванадцятипалої кишки дозволило у 22 (61,11 %) пацієнтів виконати лапароскопічну дуоденокорекцію, у 2 (5,56 %) хворих — лапароскопічно-асистовану дуоденокорекцію, але у кожного шостого (18,18 %) пацієнта були підстави до виконання хірургічного втручання через лапаротомний доступ.

Epidemiology and treatment of perforated duodenal ulcer in Kemerovo Region

Aim.To estimate the frequency of ulcerative bleeding, pyloric stenosis, need for pyloroplasty and the justification of vagotomy for perforated duodenal ulcer.Materials and Methods.We analyzed the surgical treatment of patients with perforated duodenal ulcer admitted to Podgorbunskiy Regional Clinical Emergency Hospital during 1999-2019.Results.In 2018, the number of surgical interventions due to perforated duodenal ulcer decreased by 56.4% in comparison with 1998. In 8.6% and 2.1% of patients, perforated duodenal ulcer was combined with pyloric stenosis and bleeding, respectively, requiring Judd pyloroplasty (diamond- shaped transverse excision) or gastroduodenotomy followed by Heineke-Mikulicz pyloroplasty (transversely closed longitudinal incision across the pylorus) and vagotomy. Distal gastric resection by Billroth’s operation II was required in 2.8% of patients. Repeated admission of patients with duodenal ulcer complications has been observed after isolated suturing of perforated duodenal ulcer.Conclusion.Over the last 20 years, the amount of surgical interventions because of perforated duodenal ulcer in Kemerovo Region decreased more than twofold. In > 10% patients, pyloric stenosis and bleeding require a gastric drainage. In > 8% patients, perforated duodenal ulcer is combined with pyloric stenosis; in these cases, Heineke-Mikulicz pyloroplasty may be a treatment of choice. In > 2% patients, perforated duodenal ulcer is combined with ulcerative bleeding requiring excision of the ulcer and optional distal gastric resection. Pyloroplasty may be combined with vagotomy to normalise the proteolytic activity of gastric acid.

Open versus laparoscopic repair of perforated duodenal ulcer: a comparative study

Background: Surgery is the mainstay of the treatment for perforated duodenal ulcer by closing the perforation with or without omental patch. There are no controversies in the surgical treatment of perforated duodenal ulcer but the best approach to surgery is still debatable. Advances in minimal access surgery has made it possible to close the perforated duodenal ulcer laparoscopically. The present study was conducted to compare the results of open and laparoscopic repair of perforated duodenal ulcer in terms of operative time, postoperative pain, hospital stay, and post-operative complications etc.Methods: The study was conducted in Dr. V. M. Government Medical College and Hospital located in Solapur (Maharashtra) from December 2008 to December 2010. It was a prospective comparative study. Patients were randomly divided into 2 groups alternately where group A and B were operated by conventional and laparoscopic techniques respectively and their outcomes were compared.Results: Most commonly affected age in this study was 51 to 60 years with male preponderance. Post-operative pain, analgesic requirement, wound infection, hospital stay, was significantly less in laparoscopic group as compared to open group (p<0.05).Conclusions: Laparoscopic repair of perforated duodenal ulcer is safe and feasible in properly selected patients and has superior results as compared to open surgery.

Need for pyloroplasty and vagotomy in case of perforated duodenal ulcer

Aim. Estimation of the incidence of stenosis, need for pyloroplasty and validity of vagotomy for perforated duodenal ulcer (PDU).
 Materials and methods. Twenty-year nature of surgical treatment of patients with PDC in the hospital surgery clinic is analyzed.
 Results. Over 20 years, 726 patients were operated on: 151 women (20.8%), 575 men (79.2%), mean age 39.1±6.3 years. Surgeries were performed both from laparotomic access and video laparoscopically. It is found that PDU is combined with stenosis in 8.5% and with bleeding in 1.6%, which requires Jadd excision of an ulcer on the anterior wall or gastroduodenotomy for flashing a bleeding ulcer on the posterior wall (0.7%) with subsequent Heineke — Mikulicz pyloroplasty and vagotomy. Both stem vagotomy and selective proximal were used by the method of skeletonization of lesser curvature or chemoneurolysis. Suturing with selective proximal vagotomy was performed in 567 patients, isolated suturing — in 77. B-II distal gastric resection was required in 2.1%. Repeated admission of patients with complications of a duodenal ulcer is observed after isolated suturing of PDU without surgical intervention in the mechanisms of ulcer formation.
 Conclusion. During surgical treatment of PDU are found in 79.2% of men, in 20.8% of women. There is an emerging stenosis in 8.5% of those who have PDU, which requires a gastric drainage operation. The subjects of choice may be Heineke-Mikulicz pyloroplasty or Jadd excision of an ulcer on the anterior wall. It is advisable to suture or excise an ulcer with pyloroplasty accompanied by vagotomy that normalizes the acid-proteolytic activity of gastric juice in the postoperative period and eliminates need for antisecretory drugs to prevent the recurrence of the disease.

Single‐Port Laparoscopic Repair of Perforated Duodenal Ulcers

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. 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. 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 ± 0.2cm. The mean operation time was 63.0 ± 26.6min. Meantime a nasogastric tube remained in place was 2.9 ± 0.8days. Mean duration of analgesic use was 2.8 ± 0.8days. 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 ± 1.2days. 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 treatment of gastroduodenal perforations

A 93-year-old patient underwent endoscopic treatment of perforated duodenal ulcer after previous laparoscopic suturing complicated by failure of sutured defect. A self-expanding nitinol stent with partial polyurethane coating was used. Positive effect of the treatment was noted. Further study of this method and its clinical introduction in case of favorable results can significantly reduce the incidence of complications and mortality in patients with perforated gastroduodenal ulcers.

Laparoscopy in Acute Care Surgery: Repair of Perforated Duodenal Ulcer

Introduction: The use of laparoscopic management as a first choice for the treatment of duodenal perforation is gaining ground but is not routine in many centers. In this report, we aim to report our experience with laparoscopy as the first approach for the repair of duodenal perforation. Materials and Methods: This is a retrospective review of patients during our initial experience with the use of laparoscopy for the treatment of duodenal perforation between 2009 and 2013. Results: A total of 100 patients underwent management of duodenal perforation. Laparoscopy was attempted initially in 76 patients (76%) and completed in 64 patients (64%). The length of hospital stay was shorter in the laparoscopic group (mean 2.6) than in the open group (mean 3.1) (p = 0.008). Complications developed in 14 patients (20%). There was a tendency towards fewer admissions to intensive care, less acute kidney injuries, and less acute respiratory distress syndrome in the laparoscopic group. In patients who underwent laparoscopic surgery, the chances of uneventful recovery were 4.3 times higher than in those patients who underwent open surgery (95% CI 1.3–13.5, p = 0.014). Conclusions: Laparoscopy in the treatment of perforated duodenal ulcer is safe and can be utilized as a routine approach for the treatment of this pathology.

Laparoscopic and open repair for perforated duodenal ulcer: single-center experience.

IntroductionPerforation is a dangerous complication of peptic ulcer disease and requires emergency surgical treatment. In recent decades laparoscopic repair of duodenal perforation has been widely used in emergency abdominal surgery.AimTo analyze laparoscopic and open surgical treatment of 120 consecutive patients with perforated duodenal ulcer.Material and methodsThe study included a group of 120 consecutive patients, operated on for perforated duodenal ulcer in a single institution. Laparoscopic or open repair with or without an omental patch was performed. The value of the Boey score was investigated in predicting the outcomes of treatment in the entire study group.ResultsIn 61 (50.8%) cases open repair was performed, in 56 (46.7%) cases laparoscopic repair, and in 3 (2.5%) cases conversion was performed. In the laparoscopy group the mean hospital stay was 5 days (range: 3–14), in the open group 11.7 days (range: 6–63), and in the conversion group 9.3 days (8–10) (p < 0.001). There was a significant difference between characteristics of patients in the laparoscopic groups: in the second period of laparoscopic procedures (2014–2017) the duration of the operation was significantly shorter and the number of postoperative complications was significantly lower than in the initial study group (2010–2013).ConclusionsThe laparoscopic approach is an effective method for treatment of perforated duodenal ulcer in selected cases. A number of 20–25 cases for the surgeon operating with the laparoscopic method is sufficient to achieve an acceptable level of expertise. More prospective randomized studies are needed to evaluate the effectiveness of laparoscopic repair of perforated duodenal ulcer.

Single Incision Laparoscopic Peptic Ulcer Repair with the Use Extracorporeal Mishra Knot: A Case Report.

Background: Single-port laparoscopic surgery is increasingly being used in cases of complex and complicated laparoscopic surgical intervention. We present a case of the cost effective Mishra’s extracorporeal knotting approach for treatment of a perforated duodenal ulcer (PUD). Methods: We present a case report of a patient with perforated duodenal ulcer who underwent single-port laparoscopic repair. She had peritoneal lavage and suture of the perforation using the Mishra’s knot. This was reinforced with an omental patch repair. After surgery, the patient was placed on an indefinite course of proton pump inhibitors. Results: We successfully completed the procedure via SILS (single incision laparoscopic surgery). We subsequently placed a drain in the right lower quadrant. The operative time was 57 min, and hospital stay was 5 days. She had minimal analgesic requirements. There was no operation-related morbidity. Follow-up to 6 months was done. Conclusions: Single-port laparoscopic repair using the Mishra knot technique is a feasible and safe Procedure. It is a cost technique for Single incision laparoscopic surgery (SILS) treatment of perforated duodenal ulcers

Roscoe R. Graham: An enduring legacy in the 21st century.

Modern advancements in surgery have led to a climate in which many classical techniques are becoming obsolete. However, the Graham patch technique for duodenal repair continues to be widely used as originally described in Dr Roscoe Reid Graham's 1937 article: an omental graft held in position over a duodenal perforation by three interrupted sutures. Primary documents including original newspaper articles and wartime documents were retrieved from the University of Toronto Archives and Records. Contemporary case reports and journal publications were analyzed. A review of current literature on applications and modifications of the Graham patch was undertaken. Roscoe Graham received his education at the University of Toronto. After his surgical training, he joined the No. 4 General Hospital as a captain in World War I. Upon returning from duty, his surgical contributions were extensive. His achievements include the development of a procedure for rectal prolapse repair, the first insulinoma resection, and the pioneering of an omental patch technique for the treatment of perforated duodenal ulcers. He was an integral member of the Toronto medical community and reputed to be among North America's best surgeons. Although many surgical techniques described in the 20th century have been discarded in favor of new technological applications, Graham's original omental patch is still used across the world. In addition to providing an effective solution to perforated ulcer repair in both open and laparoscopic procedures, it has been adapted for use in traumatic solid organ injury. This article describes the life and career of Roscoe Reid Graham, highlights his medical contributions, and explores how his omental patch technique continues to be indispensable on the modern surgical stage.

MID-TERM OUTCOME OF PERFORATED DUODENAL ULCER REPAIR USING SINGLE-PORT LAPAROSCOPIC SURGERY

Background: Single-port laparoscopic surgery (SPLS) is increasingly used in surgery and in the treatment of perforated duodenal ulcer. The aim of this study was to evaluate mid-term outcome of perforated duodenal ulcer repair using SPLS. Methods: A prospective study on 72 consecutive patients diagnosed with perforated duodenal ulcer and treated with SPLS at Hue University Hospital and Hue Central Hospital from January 2012 to Mars 2016. Results: The mean age was 48.8 ± 14.0 (17 - 79) years. Male/female ratio was 17.0. Four patients (5.6%) with history of abdominal surgery were successfully treated by pure SPLS. Patients were classified as ASA 1, ASA 2 and ASA 3 in 86.1%, 12.5%, and 1.4% of cases, respectively. Using Boey scoring system, there were 86.1% and 12.5% of cases classified as Boey 0 and Boey 1 while there were no Boey 2 and 3 cases. The average size of perforation was 4.1 ± 2.6 (1.5-22) mm. The perforation was situated on the anterior duodenal wall in 98.6% of cases and on the posterior duodenal wall in 1.4% of cases. There was one case (1.4%) in which one additional trocar was required. Conversion to open surgery was necessary in one patient (1.4%) in which the perforation was situated on the posterior duodenal wall. Average length of hospital stay was 5.7 ± 1.2 (4-12) days. Post-operative complications rate was 2.8%. There was no leakage from the repair site, no port-site hernia and no post-operative mortality. At 2-month follow-up visit, patients were classified as Visick 1 in 95.1% of cases and Visick 2 in 4.9% of cases and the duodenal ulcer was completely healed on gastroduodenoscopy in 86.7% of cases. At 12-month follow-up, patients were classified as Visick 1 in 93.5% of cases and Visick 2 in 4.3% of cases. There was one case (2.2%)diagnosed with recurrent duodenal ulcer perforation at 5 months after the repair of the first perforation. On gastroduodenoscopy, recurrent duodenal ulcer was seen in 8.9% of cases. Conclusions: SPLS is a safe method for the treatment of perforated duodenal ulcer. Conversion rate was 1.4%. Recurrent duodenal ulcer rate was 8,9% and recurrent duodenal ulcer perforation rate was 2.2% after 12-month follow-up. Key words: perforated duodenal ulcer, single port laparoscopic repair, single port laparoscopy

FACTORS INFLUENCING THE OPERATION TECHNIQUE OF PEFORATED DUODENAL ULCER REPAIR BY SINGLEPORT LAPAROSCOPIC SURGERY

Background: Single-port laparoscopic surgery (SPLS) is increasingly used in surgery and in the treatment of perforated duodenal ulcer. The aim of this study was to evaluate technical factors for perforated duodenal ulcer repair by SPLS. Methods: A prospective study on 42 consecutive patients diagnosed with perforated duodenal ulcer and treated with SPLS at Hue university of medicine and pharmacy hospital and Hue central hospital from January 2012 to February 2015. Results: The mean age was 48.1 ± 14.2 (17 - 79) years. 40 patients were treated with suture of the perforation by pure SPLS. There was one case (2.4%) in which one additional trocar was required. Conversion to open surgery was necessary in one patient (2.4%) in which the perforation was situated on the posterior duodenal wall. Two patients (4.8%) with history of abdominal surgery were successfully treated by pure SPLS. The size of perforation was correlated with suturing time (correlation coefficient r = 0.459) and operative time (correlation coefficient r = 0.528). Considering suture type, X stitches were used in 95.5% cases, simple stitches were used in one case (2.4%) while Graham patch repair technique was utilized in one case (2.4%) with large perforation. Most cases (95.1%) required only simple suture without omental patch. Peritoneal drainage was spared in most cases (90.2%). Conclusions: SPLS is a safe method for the treatment of perforated duodenal ulcer. Posterior duodenal location is the main cause of conversion to open surgery. Factor related to operative time is perforation size. Key words: perforated duodenal ulcer, single port laparoscopic repair, single port laparoscopy

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

IntroductionAlthough the surgical treatment of patients with perforated duodenal ulcer is the method of choice, the introduction of effective pharmacotherapy has changed the surgical strategy. Nowadays less extensive procedures are chosen more frequently. The introduction of laparoscopic procedures had a significant impact on treatment results.AimTo present our experience in the treatment of perforated duodenal ulcer in two periods, by comparing open radical anti-ulcer procedures with laparoscopic ulcer repair.Material and methodsThe analysis covered patients operated on for perforated duodenal ulcer. Two groups of patients were compared. Group 1 included 245 patients operated on in the period 1980–1994 with a traditional method (pyloroplasty + vagotomy) before introduction of proton pump inhibitors (PPI). Group 2 included 106 patients treated in the period 2000–2014 with the laparoscopic technique supplemented with PPI therapy. Groups were compared in terms of patients’ demographic structure, operative time, complication rate and mortality.ResultsThe mean operative time in group 1 was shorter than in group 2 (p < 0.0001). Complications were noted in 57 (23.3%) patients in group 1 and 14 (13.5%) patients in group 2 (p = 0.0312). Reoperation was necessary in 13 (5.3%) cases in group 1 and in 5 cases in group 2 (p = 0.8179). The mortality rate in group 1 was significantly higher than in group 2 (10.2% vs. 2.8%, p = 0.0192). In group 1, median length of hospital stay was 9 days and differed significantly from group 2 (6 days, p < 0.0001).ConclusionsWithin the last 30 years, significant changes in treatment of perforated peptic ulcer (PPU) have occurred, mainly related to abandoning routine radical anti-ulcer procedures and replacing the open technique with minimally invasive surgery. Thus it was possible to improve treatment results by reducing complication and mortality rates, and shortening the length of hospital stay. Although the laparoscopic operation is longer, it improves outcomes. In the authors’ opinion, in each patient with suspected peptic ulcer perforation, laparoscopy should be the method of choice.

Perforated duodenal ulcer in a child: An unusual complication of malaria

Gastrointestinal symptoms such as dyspepsia, vomiting, diarrhea, hepatitis, gastrointestinal bleed, abdominal pain, subacute intestinal obstruction like presentation and acute abdomen are common in acute malaria. However, perforated duodenal ulcer (PDU) complicating acute malaria in a child is a rare occurrence and uncommonly heard of. The exact mechanism of duodenal ulcer perforation in malaria is not clear due to the paucity of reported cases, and it may be multifactorial in etiology. The treatment of PDU in children is similar to adults that is surgical by omental patch repair of the perforation. We present an unusual case of PDU in a pediatric patient of malaria. The search of English literature revealed only one more reported case of PDU associated with malaria.

Re: Gonenc M, Dural AC, Celik F, et al: Enhanced postoperative recovery pathways in emergency surgery: a randomized controlled clinical trial

First suggested for patients with perforated gastric ulcers in 1894, 1 Bennet W.H. A case of ruptured gastric ulcer successfully treated by immediate suture. Lancet. 1894; 2: 21-22 Abstract Scopus (4) Google Scholar omental patch closure of a perforated duodenal ulcer was popularized by Graham in 1937 2 Graham R.R. The treatment of perforated duodenal ulcers. Surg Gynecol Obstet. 1937; 64: 235-238 Google Scholar and has remained a surgical mainstay. Over time and before the descriptions of Helicobacter pylori, H2-receptor antagonists, and proton-pump inhibitors, omental patch closure was one of the 4 operations used to treat perforated gastroduodenal ulcers. These included gastrectomy for perforated gastric ulcers and truncal vagotomy and pyloroplasty, truncal vagotomy and resection, and proximal gastric vagotomy with omental patch closure for perforated duodenal ulcers. 3 Feliciano D.V. Surgical options and results of treatment of perforated ulcers. Problems Gen Surg. 1987; 4: 301-307 Google Scholar , 4 Feliciano D.V. Do perforated duodenal ulcers need an acid-decreasing surgical procedure now that omeprazole is available?. Surg Clin N Am. 1992; 72: 369-380 PubMed Google Scholar , 5 Jordan Jr., G.L. DeBakey M.E. Duncan Jr., J.M. Surgical management of perforated peptic ulcers. Ann Surg. 1974; 179: 628-633 Crossref PubMed Scopus (49) Google Scholar These “definitive” operations were used from the 1940s to the 1990s because of the following problems or limitations of omental patch closure as follows: (1) technical difficulties in patching gastric or large duodenal perforations; (2) early reperforation or bleeding; (3) recurrent symptoms (73% of patients) postoperatively 5 Jordan Jr., G.L. DeBakey M.E. Duncan Jr., J.M. Surgical management of perforated peptic ulcers. Ann Surg. 1974; 179: 628-633 Crossref PubMed Scopus (49) Google Scholar ; (4) late reperforation (9% of patients) 6 Griffin G.E. Organ Jr., C.H. The natural history of the perforated duodenal ulcer treated by suture plication. Ann Surg. 1976; 183: 382-385 Crossref PubMed Scopus (46) Google Scholar ; and (5) a large number of reoperations (48% of patients). 7 Skovgaard S. Late results of perforated duodenal ulcer treated by simple suture. World J Surg. 1977; 1: 521-526 Crossref PubMed Scopus (12) Google Scholar Enhanced postoperative recovery pathways in emergency surgery: a randomised controlled clinical trialThe American Journal of SurgeryVol. 207Issue 6PreviewEnhanced recovery pathways are now widely used in elective surgical procedures. The feasibility of enhanced postoperative recovery pathways in emergency surgery for perforated peptic ulcer disease was investigated in this randomized controlled clinical trial. Full-Text PDF

Laparoscopic Repair of Duodenal UlcerPerforation: A Randomized Controlled Clinical Trial

Background: Omental patch repair with peritoneal lavage is the mainstay of treatment for perforated duodenal ulcer in many institutions. The literature established that laparoscopic repair of perforation when compared to open repair, is associated to lower wound dehiscence, less analgesic use, less pain and hospital stays. The drawbacks are length of operative time and the laparoscopic surgeon's experience in intra corporeal suturing and knotting. Methods: Over a one year period 83 patients presenting with perforated duodenal ulcer were randomly assigned to undergo either an open or a laparoscopic omental patch repair. They were excluded for a history of upper abdominal surgery, concomitant evidence of bleeding from the ulcer, or gastric outlet obstruction. Those with clinically sealedoff perforations without signs of peritonitis or sepsis were treated without surgery. The endpoint was operative time, postoperative pain score, post-operative analgesic requirement, and length of postoperative hospital stay, morbidity, mortality and the date of return to normal daily activities. Results: Out of a total of 95 cases with diagnosis of duodenal perforations, 12 were excluded and 83 patients were analyzed. Both the groups were comparable in terms of age, gender, duration of symptoms, history of acid peptic disease, NSAIDs use, presence of comorbid conditions and size of perforation. Most of them presented after 24 hrs of onset of pain with the mean duration of 54.58 ± 32.4 hrs. There was one conversion in laparoscopic group due to intolerance to pneumoperitoneum. The duration of surgery was not significantly different but was high in the first five laparoscopic repairs (mean 91 mins as compared with 65 mins for the last 5 laparoscopic repairs). Those in laparoscopic group had significantly (p<0.001) less postoperative pain, analgesic requirement, time to return to normal diet, full ambulation and hospital stay. Morbidity was significantly high in open group (36.29 % vs 13.88 % in laparoscopic group; p 0.01). Open group had significantly high surgical site infection (19.14 vs 0%; p 0.005) and chest infection (29.78 vs 11.11%; p 0.04). One case in each group had mortality. Conclusion: Laparoscopic repair is safe and is a reliable procedure even in delayed presentation. It has significantly less postoperative pain, less need for analgesics, shorter hospital stay, early return to normal diet and work, and less complications without any difference in mortality.

Single-port laparoscopic repair of a perforated duodenal ulcer: intracorporeal “cross and twine” knotting

Single-port laparoscopic surgery is increasingly used to treat various types of diseases requiring surgical intervention. We present the technique and the results of our simple "cross and twine" intracorporeal knotting approach for treatment of a perforated duodenal ulcer. From January 2009 to October 2009, 13 patients with perforated duodenal ulcers underwent single-port laparoscopic repair. The laparoscopic procedure included peritoneal lavage and suture of the perforation. The omentum above the repair site was then reinforced. After surgery, patients took an H2 receptor antagonist for 8 weeks and then underwent follow-up gastrofiberscopy. All procedures were completed under the conditions described. The mean operative time was 90.2 ± 24.2 min, and the mean hospital stay was 6.1 ± 0.5 days. The mean number of times that opiates were used for pain was 0.5 ± 1.0, and wound length was 1.9 ± 0.1 cm. There was no operation-related morbidity. Follow-up gastrofiberscopy revealed good lesion healing. Single-port laparoscopic repair using the "cross and twine" knotting technique is a feasible and safe procedure, and it may be a less invasive laparoscopic surgical technique for scarless surgical treatment of perforated duodenal ulcers.

穿孔性十二指腸潰瘍の診断と治療法の選択における超音波検査の有用性

穿孔性十二指腸潰瘍の診断と治療法の選択における超音波検査の有用性

Feasibility of ultrasonography in determining the diagnosis and treatment of perforated duodenal ulcer.

We diagnosed and treated perforated duodenal ulcers (PDUs) based on the results of ultrasonography (US). We obtained useful ultrasonographic findings regarding the diagnosis and treatment of PDU. We experienced 24 PDU cases over 6 years and 4 months (March 2002 to June 2008), and evaluated five useful ultrasonographic findings regarding PDU: (1) Two-way transmigration of liquid and air bubbles through the perforated duodenal wall, (2) hyperechoic band penetration out through the duodenal wall, (3) free air exiting the PDU, (4) fluid exiting the PDU, and (5) liver covering the PDU. Of the 24 cases, two-way transmigration was observed in 4 cases, hyperechoic band penetration was observed in 18 cases, and exiting free air and fluid was observed in all cases. In all patients with two-way transmigration of liquid and air bubbles, we could immediately diagnose PDU. For the PDU cases falling under categories 2, 3, and 4 above, upon analysis, a large majority provided useful ultrasonographic findings for diagnosing PDU. Of the 5 cases in which the liver did not cover the PDU at all, two-way transmigration of liquid and air bubbles was observed in 4 cases, and surgery was performed in all 5 cases. Of the 19 cases where the PDU was completely covered by the surrounding organs (the liver in 16 cases and fatty organs such as the round ligament or the omentum in 3 cases), nonsurgical treatment was selected in 18 cases. As a result, patients with PDUs covered by surrounding organs, mainly by the liver, received nonsurgical treatment, whereas those with noncovered PDUs underwent surgery. The findings of ultrasonography are useful for diagnosing and determining the treatment of PDU.