perfor peptic ulcer treatment

7/27/2019 perfor peptic ulcer treatment

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Perforated peptic ulcer


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Perforated peptic ulcerfamous fatalities

NapoleonJames Joyce

Rudolph Valentino


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Perforated peptic ulcerAcute abdomen (De Dombal n=30.000)

Appendicitis 28%

Cholecystolithiasis 9.7%

Occluded small intestine 4.1%

Gynecologic disorders 4.0%

Acute pancreatitis 2.9%

Urologic diagnosis 2.9%

Perforated peptic ulcer 2.5% (5-10 pro year)

Other diagnosis 1.5%

No diagnosis >40%


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Perforated peptic ulcerPathology

Most often chronic ulcer

50%: sealed off

Location: most oftenanterior juxtapyloric

Mean diameter: 5mm(>1cm=giant ulcer: rare)

10%: perforated gastriculcer)


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Perforated peptic ulcermorphology related to location

juxta-pyloric ulcer:

small, healthy border

gastric ulcer at lesser curvature:

large, fibrotic edematous border

(ulcus callosum)


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perforated gastric carcinoma


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Perforated peptic ulcersealing off by left liver half


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Perforated peptic ulcersealing off by segment IV


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Perforated peptic ulcersealing off by left liver lobe

X: free air below diaphragm in this patient


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Perforated peptic ulcerfibrinous peritonitis+parahepatic collection


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Perforated peptic ulcerulcer visible after lifting left liver lobe


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Perforated peptic ulcerBacteriology

48h: infected peritonitis, most often grampositive initially,

later gramnegative


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Perforated peptic ulcercause of death: peritonitis

Pre-antibiotics-mortality: 75%


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Perforated peptic ulcersubphrenisch abces


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Perforated peptic ulcerBoey prognostic parameters

Age Duration of symptoms

Shock

ASA III-IV

Diameter of ulcer


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Diagnosis


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Diagnosis


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Perforated peptic ulcerDiagnosis

1) X-thorax/abdomen in upright position If negative:

2) CT with oral contrast


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Perforated peptic ulcerduration of postoperative pneumoperitoneum

X:


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Operative therapy (history)

1892 resection: Heusner

1894 oversewe: Dean

1937 omental patch: Graham

1990 laparoscopy: Mouret

(1947 Taylor: conservative)


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Perforated peptic ulcerOperative therapy (closure+lavage)

Only after resuscitation

Closure+lavage

Postoperative gastric aspiration

Acid suppression (PPI s)

Antibiotics


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Perforated peptic ulcerlaparoscopic closure


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Perforated peptic ulcerlaparoscopic closure


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(stapler-fixation of omentum)


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Perforated peptic ulcerrendez vous omental patch


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Perforated peptic ulcerGraham 1937: omental patch plication (without primary closure of ulcer)

Kathkouda et al 1993: laparoscopic Graham omental patch


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3 stitch-Graham omental patch

Lam et al. Surg Endosc 2005; 19: 1627-30

Distance ulcer>1cm


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3 stitch-Graham omental patch


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Flat tire test


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drain?


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Perforated peptic ulceroperative therapy: abdominal complications

Re-leakage: 10%

Intra-abdominal abscess: 3%


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Perforated peptic ulceroperative therapy: results

Mortality: 0-8%

Morbidity: 13-23%

Parameters: ASA-, Boey scores

In general: results correlated with duration of symptoms,

ulcer diameter, age


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Management strategies, early results, benefits, and risk factors of laparoscopic repair of

perforated peptic ulcer.

Lunevicius R, Morkevicius M.

World J Surg 2005; 29: 1299-310

2nd Department of Abdominal Surgery, Clinic of General and Plastic Surgery, Orthopaedics, and

Traumatology, Vilnius University Emergency Hospital, Vilnius University, Siltnamiu Street 29, LT-

04130 Vilnius, Lithuania. [email protected]

The primary goal of this study was to describe epidemiology and management strategies of the

perforated duodenal ulcer, as well as the most common methods of laparoscopic perforated

duodenal ulcer repair. The secondary goal was to demonstrate the value of prospective and

retrospective studies regarding the early results of surgery and the risk factors. The tertiary goalwas to emphasize the benefits of this operation, and the fourth goal was to clarify the possible risk

factors associated with laparoscopic repair of the duodenal ulcer. The Medline/Pubmed database

was used. Review was done after evaluation of 96 retrieved full-text articles. Thirteen prospective

and twelve retrospective studies were selected, grouped, and summarized. The spectrum of the

retrospective studies' results are as follows: median overall morbidity rate 10.5 %, median

conversion rate 7%, median hospital stay 7 days, and median postoperative mortality rate 0%. The

following is the spectrum of results of the prospective studies: median overall morbidity rate was

slightly less (6%); the median conversion rate was higher (15%); the median hospital stay was

shorter (5 days) and the postoperative mortality was higher (3%). The risk factors identified werethe same. Shock, delayed presentation (> 24 hours), confounding medical condition, age > 70

years, poor laparoscopic expertise, ASA III-IV, and Boey score should be considered preoperative

laparoscopic repair risk factors. Each of these factors independently should qualify as a criterion for

open repair due to higher intraoperative risks as well as postoperative morbidity. Inadequate ulcer

localization, large perforation size (defined by some as > 6 mm diameter, and by others as > 10

mm), and ulcers with friable edges are also considered as conversion risk factors.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi?PrId=3055&uid=16132404&db=pubmed&url=http://dx.doi.org/10.1007/s00268-005-7705-4


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Systematic review comparing laparoscopic and open repair for perforated peptic ulcer.

Lunevicius R, Morkevicius M.

Br J Surg 2005; 92: 1195-207

Clinic of General and Plastic surgery, Orthopaedics and Trauma surgery, General Surgery Centre,

Vilnius University Emergency Hospital, 29 Siltnamiu Street, LT-04130, Vilnius, Lithuania.

[email protected]

BACKGROUND: The advantages of laparoscopic over open repair for perforated peptic ulcer are

not as obvious as they may seem. This paper summarizes the published trials comparing the two

approaches. METHODS: Two randomized prospective, five non-randomized prospective and eight

retrospective studies were included in the analysis. Relevant trials were identified from theMedline/Pubmed database and the reference lists of the retrieved papers were then analysed. The

outcome measures used were operating time, postoperative analgesic requirements, length of

hospital stay, return to normal diet and usual activities, and complication and mortality rates.

Published data were tested for heterogeneity by means of a chi2 test. Meta-analysis methods were

used to measure the pooled estimate of the effect size. In total, 1113 patients are represented from

15 selected studies, of whom 535 were treated by laparoscopic repair and 578 by open repair; 102

patients (19.1 per cent) underwent conversion to open repair. RESULTS: Statistically significant

findings in favour of laparoscopic repair were less analgesic use, shorter hospital stay, less

wound infection and lower mortality rate. Shorter operating time and less suture-site

leakage were advantages of open repair. Three variables (hospital stay, operating time and

analgesic use) were significantly heterogeneous in the papers analysed.

CONCLUSION: Laparoscopic repair seems better than open repair for low-risk patients.

However, limited knowledge about its benefits and risks compared with open repair

suggests that the latter, more familiar, approach may be more appropriate in high-risk

patients. Further studies are needed.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Morkevicius+M%22%5BAuthor%5Dhttp://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=pubmed&cmd=Search&itool=pubmed_Abstract&term=%22Lunevicius+R%22%5BAuthor%5D


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Perforated peptic ulceropen closure in the morbid obese


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Perforated peptic ulcerfree intraperitoneal air-differential diagnosis


Perforated diverticulitis

Perforated appendicitis

Perforated Crohn disease

Heimlich maneuver/Boerhaave syndrome

Through salpinx

Idiopathic


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Perforated peptic ulcerLAMA-trial: open vs laparoscopic closure (Marietta Bertleff)

Raw data


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exclusion of gastric carcinoma and helicobacter


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Perforated peptic ulcerremaining questions

Best technique of closure?

Postoperative gastric aspiration?

P f t d ti l


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Tissue glue



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Stamp method

Bertleff M et al. Surg Endosc 2006 in press

perfor peptic ulcer treatment

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