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PubMed2002

Laparoscopic repair for perforated peptic ulcer: a randomized controlled trial.

OBJECTIVE: To compare the results of open versus laparoscopic repair for perforated peptic ulcers. SUMMARY BACKGROUND DATA: Omental patch repair with peritoneal lavage is the mainstay of treatment for perforated peptic ulcers in many institutions. Laparoscopic repair has been used to treat perforated peptic ulcers since 1990, but few randomized studies have been carried out to compare open versus laparoscopic procedures. METHODS: From January 1994 to June 1997, 130 patients with a clinical diagnosis of perforated peptic ulcer were randomly assigned to undergo either open or laparoscopic omental patch repair. Patients were excluded for a history of upper abdominal surgery, concomitant evidence of bleeding from the ulcer, or gastric outlet obstruction. Patients with clinically sealed-off perforations without signs of peritonitis or sepsis were treated without surgery. Laparoscopic repair would be converted to an open procedure for technical difficulties, nonjuxtapyloric gastric ulcers, or perforations larger than 10 mm. A Gastrografin meal was performed 48 to 72 hours after surgery to document sealing of the perforation. The primary end-point was perioperative parenteral analgesic requirement. Secondary endpoints were operative time, postoperative pain score, length of postoperative hospital stay, complications and deaths, and the date of return to normal daily activities. RESULTS: Nine patients with a surgical diagnosis other than perforated peptic ulcer were excluded; 121 patients entered the final analysis. There were 98 male and 23 female patients recruited, ages 16 to 89 years. The two groups were comparable in age, sex, site and size of perforations, and American Society of Anesthesiology classification. There were nine conversions in the laparoscopic group. After surgery, patients in the laparoscopic group required significantly less parenteral analgesics than those who underwent open repair, and the visual analog pain scores in days 1 and 3 after surgery were significantly lower in the laparoscopic group as well. Laparoscopic repair required significantly less time to complete than open repair. The median postoperative stay was 6 days in the laparoscopic group versus 7 days in the open group. There were fewer chest infections in the laparoscopic group. There were two intraabdominal collections in the laparoscopic group. One patient in the laparoscopic group and three patients in the open group died after surgery. CONCLUSIONS: Laparoscopic repair of perforated peptic ulcer is a safe and reliable procedure. It was associated with a shorter operating time, less postoperative pain, reduced chest complications, a shorter postoperative hospital stay, and earlier return to normal daily activities than the conventional open repair.

Adolescent↗
PubMed1995

Laparoscopic omental patch repair for perforated peptic ulcer.

OBJECTIVE: The authors' initial experience with laparoscopic omental patch repair for perforated peptic ulcer is documented. Its results are compared with those of other procedures and follow-up study is reviewed. SUMMARY BACKGROUND DATA: Since the advent of H2-antagonists, the usefulness of simple closure of a perforated peptic ulcer is increasing, and improvements in laparoscopic surgery have made possible minimally invasive surgery for perforated ulcer. METHODS: From December 1992 to February 1994, laparoscopic omental patch repair followed by use of H2-antagonists was performed successfully in 11 patients. Fifty-five patients underwent other surgical procedures for perforated peptic ulcers (conventional open omental patch: 4, selective vagotomy in combination with antrectomy: 24, distal gastrectomy: 27). RESULTS: The average operation time was 135 minutes. Administration of postoperative pain medication was reduced remarkably (0.9 times per patient), and all patients recovered rapidly. No serious postoperative complications were recorded. After a mean period of 11 months, the postoperative evaluation was satisfactory for all patients, and no ulcer recurrence was found. CONCLUSIONS: In perforated peptic ulcer disease, laparoscopic omental patch repair offers a number of advantages. Because no upper abdominal incision is made, there is decreased postoperative pain, and the patient rapidly recovers with fewer and less severe complications. Although the procedure requires a surgeon with particular expertise in endoscopic suturing technique, surgeons familiar with laparoscopic cholecystectomy can readily perform it after some practice. The authors' preliminary experience suggests that this is a minimally invasive procedure for perforated peptic ulcer that offers an attractive alternative to open surgery.

Adult↗
PubMed1962

Perforated peptic ulcer, selective gastric resection in emergency treatment.

In a series of 240 cases of perforated peptic ulcer prior to 1952 there was a total mortality of 17 per cent. This included cases treated conservatively as a planned procedure or because of other morbid conditions and undiagnosed cases, all ending in death. In cases treated by simple suture, mortality was 2.6 per cent for patients under 50 years of age and 17 per cent for those over 50, the rate rising very steeply with each decade over 50. From 1953 through 1959 selective gastric resection was carried out, the operation being done in all cases of perforated gastric ulcers, of chronic duodenal ulcers and of perforations associated with hemorrhage. During this period 303 perforated ulcers were treated, with a mortality of 15.5 per cent. Patients with associated morbid conditions and those admitted moribund and died, or died undiagnosed were again included. In this series also the mortality increased steeply from age 50 onward. Gastric resection was carried out in 148 cases of perforated peptic ulcer with a mortality of 6 per cent. In 105 cases under 60 years of age there were no deaths but in those over 60 the mortality rate was 21.8 per cent. Results in the patients who had resection, as determined after three years of observation, compared favorably with the results in patients who were treated by suture. The mortality of perforated ulcers in females was higher than in males. Emergency gastric resection has a definite place in the treatment of perforated peptic ulcer.

Aged↗
PubMed1999

Evaluation of a protocol for the non-operative management of perforated peptic ulcer.

BACKGROUND: The non-operative management of perforated peptic ulcer has previously been shown to be both safe and effective although it remains controversial. A protocol for non-operative management was set up in this hospital in 1989. Adherence to the guidelines in the protocol has been audited over a 6-year period with a review of outcome. METHODS: The case-notes of patients with a diagnosis of perforated peptic ulcer were reviewed. Twelve guidelines from the protocol were selected for evaluation of compliance to the protocol. RESULTS: Forty-nine patients underwent non-operative treatment initially. Eight patients failed to respond and underwent operation. Complications included abscess formation (seven patients), renal failure (one), gastric ileus (one), chest infection (two), and cardiac failure and stroke (one). Four deaths occurred in this group. Adherence to certain protocol guidelines was poor, notably those concerning prevention of thromboembolism, use of antibiotics, use of contrast examination to confirm the diagnosis and referral for follow-up endoscopy. Two gastric cancers were detected on subsequent endoscopy. CONCLUSION: This experience demonstrates that non-operative treatment can be used successfully in a general hospital. Adherence to protocol guidelines was found to be variable and the protocol has therefore been simplified. This study highlights the need for an accurate diagnosis and the importance of follow-up endoscopy.

Adolescent↗
PubMed1995

Anaesthesia for laparoscopic closure of perforated peptic ulcer--any harm or benefit?

Laparoscopic closure of perforated peptic ulcer is technically feasible (1). Haemodynamic changes during laparoscopic operations are known and may have an adverse influence on outcome in patients who have peritonitis, are hypovolemic or even septic (2-4). A complete physiological understanding of CO2-inflation of an abdomen in diffuse peritonitis is still missing. The purpose of this study is to compare perioperative variables of general anaesthesia in patients undergoing open or conventional laparoscopic closure of perforated peptic ulcer.

Abdomen↗
PubMed2006

Gastric body partition for giant perforated peptic ulcer in critically ill elderly patients.

BACKGROUND: To prevent or minimize leakage after simple closure of giant perforated peptic ulcers in critically ill elderly patients, we conducted a clinical study using gastric body partition to prevent upstream gastric juice and food from passing through the sutured ulcer. METHODS: Ten critically ill elderly patients with giant (> 2.5 m) perforated peptic ulcer were included in the study of gastric body partition. RESULTS: The patients' mean age was 78.2 years and mean delay in treatment was 95.6 hours. None of the 10 patients had major complications after operation, although minor leakage of the sutured ulcer occurred in 4 patients. Only one patient presented with recurrent anastomotic ulcer and one patient died 28 days after surgery. CONCLUSIONS: Gastric body partition and gastrojejunostomy, in addition to simple closure of a giant perforated peptic ulcer, could be a quick, easy, and potentially effective alternative to avoid or at least to minimize leakage of the sutured ulcer. Moreover, gastric body partition, unlike antral partition, might not necessarily increase risks of hypergastrinemia and marginal ulcer.

Aged↗
PubMed1998

A randomized comparison of acute phase response and endotoxemia in patients with perforated peptic ulcers receiving laparoscopic or open patch repair.

BACKGROUND: In patients with peritonitis from perforated peptic ulcers, we compared acute stress responses, endotoxemia, and bacteremia following laparoscopic or open surgery. PATIENTS AND METHODS: Consecutive patients with peritonitis from perforated peptic ulcers were randomized to receive laparoscopic sutured or open omental repair. Undiluted peritoneal fluid was obtained at surgery for quantitative bacterial and endotoxin (Limulus Amoebocyte Lysate) assay. Serial blood samples were taken at 0, 30, 60, 90, 120, and 180 minutes, and at 12, 24, 48, 72, and 120 hours for determinations of quantitative bacterial and endotoxin assays, interleukin-6 (IL-6), C-reactive protein (CRP), and cortisol. RESULTS: Twenty-two patients were randomized: laparoscopy group (n = 12), open repair group (n = 10). Conversions were required in 3 patients assigned to laparoscopy, leaving 9 patients for analysis. The two groups were comparable in their demographic data, median duration of perforation (13.5 hours versus 10 hours), severity of peritoneal contamination as indicated by viable bacterial count (5.9 x 102 versus 1.5 x 10(2) colony forming unit/mL) and endotoxin concentration in peritoneal fluid (27.2 versus 24.6 EU/mL). No significant endotoxemia or bacteremia was detected in these patients. Median interleukin-6 was highest at 0 hour (1520 versus 962 pg/mL) and fell rapidly following surgery. C-reactive protein peaked at 24 hours and plateaued thereafter. Cortisol was highest intraoperatively and fell thereafter. No difference was noted between the two treatment groups with respect to these inflammatory markers (IL-6 P = 0.19, CRP P = 0.14, cortisol P = 0.56, multivariate analysis of variance). CONCLUSION: Endotoxemia and bacteremia are insignificant in most patients with perforated peptic ulcers. In patients with perforated peptic ulcers, laparoscopic patch repair does not reduce acute stress responses when compared with open surgery.

Acute-Phase Proteins↗