Acute perforated duodenal ulcer

This report is based on a personal experience with nineteen patients who were operated upon for acute perforation of a duodenal ulcer. Closure of the perforation and posterior gastroenterostomy was done in all and in twelve the appendix was removed. Drainage was used in only two cases. There was one death. This patient who was admitted in a state of shock five hours after perforation and operated upon at once died twenty-four hours later. The youngest, and only female in the group, was a girl of eighteen years. This is not a selected group but one which contains all cases of acute perforated duodenal ulcer which have come under my care in the past fifteen years.Many perforated duodenal ulcers become sealed temporarily to the undersurface of the liver, thereby preventing for a time widespread contamination of the peritoneum.Acute perforation is the result of an acute ulcerative process in either a recent or an old ulcer. The perforation is caused by erosion (acid) and not by rupture from increased pressure.The operation of choice should be closure of the perforation and posterior gastroenterostomy. The closure is made by three or four through-and-through cotton sutures re-enforced by several nearby fat tabs. Do not infold; do not use a purse-string suture.Except in the presence of advanced peritonitis, gastroenterostomy is advisable because (1) perforation does not cure the ulcer. Simple closure is followed by recurrence of ulcer in 40 to 60 per cent of the patients and in others the stomach may have motor difficulty from fixation of the pylorus to the undersurface of the liver. Gastroenterostomy is the best safeguard against recurrence and motor dysfunction of the stomach. (2) It protects the sutured area of perforation against tension and leakage. (3) It does not increase the operative risk.When the appendix is readily accessible, it should be removed. Spinal anesthesia is recommended except in the presence of shock. Drainage is rarely indicated.     

Anisakiasis presenting as perforated ulcer of the cecum

A case of cecal anisakiasis is presented. Symptoms were compatible with appendicitis. The patient was operated and a perforated ulcer of the cecum was found. Ileocolic resection was performed. The histologic result showed the presence of Anisakis simplex larva in the muscle of the cecum. The patient was discharged the fifth day without complications. At present he is asymptomatic. He had eaten uncooked anchovies some days before the onset of the disease.     

Minilaparotomy for perforated duodenal ulcer

The usefulness of the minilaparotomy approach for perforated duodenal ulcer repair was retrospectively evaluated in 37 patients (26 men; mean age, 56.5 years). Simple closure with an omental patch by minilaparotomy (skin incision, < or = 7 cm) was successful in 86.5% of the cases, with an operative mortality of 2.7%. Compared with the results in historic control patients who underwent conventional open surgery (n = 27), a shorter operative time (P < 0.01), lower frequency of analgesic use (P = 0.03), earlier passage of flatus (P < 0.01), and shorter hospital stay (P = 0.04) were obtained in the patients undergoing minilapartomoy. The postoperative morbidity was identical between the two groups (16.2% versus 33.3%, P = 0.40). On multivariate analysis, a large amount of intraabdominal fluid was the only significant risk factor for extension of the minilaparotomy wound (P = 0.012). The minilaparotomy approach appears to be a feasible, safe, and less invasive approach compared with the conventional open approach and could be a useful alternative to the laparoscopic approach in selected patients with perforated duodenal ulcer.     

Laparoscopic closure of perforated duodenal ulcer

Background: Medical treatment of peptic ulcer is highly successful, and the eradication of Helicobacter pylori (H. pylori) reduces ulcer recurrence. However, the incidence of perforated duodenal ulcer and its associated mortality have not been reduced by modern methods of therapy. Laparoscopic simple closure and omental plug by suturing, fibrin glue, and stapler have been successful. Methods: Over a 1-year period (1996–97), 21 patients with perforated duodenal ulcer were operated on in our hospital by laparoscopic simple closure and omental patch. The mean age was 36.4 ± 11.8 years (range, 18–61). Twenty patients were male (93.7%). The mean duration of pain was 9.1 ± 11.7 hs (range, 2–48). Three patients had a previous history of duodenal ulcer (14.3%), and another three (14.3%) patients had a history of nonsteroidal antiinflammatory drug (NSAID) intake. Erect chest radiograph showed that 19 patients had air under the diaphragm (90.5%). Sixteen patients (76.2%) had frank pus in the abdomen, and five patients had a minimal peritoneal reaction (23.8%). Results: The mean operative time was 71.6 ± 24.6 mins (range, 40–120), and the mean hospital stay was 5.2 ± 1.6 days (range, 3–9). The mean time to resume oral fluids was 3.1 ± 0.8 days (range, 2–4). Only one patient was reoperated due to leakage identified by gastrographin swallow. Conclusions: This procedure is safe and efficient; however, further study of its long-term effectiveness and comparability to existing therapy is still needed. Received: 28 May 1998/Accepted: 17 November 1998     

Nonoperative treatment of perforated duodenal ulcer

This report concerns 35 adult patients in whom perforation of a duodenal or prepyloric ulcer was treated nonoperatively between July 1979 and April 1988 at the Los Angeles County--University of Southern California Medical Center, Los Angeles. Each patient had pneumoperitoneum with clinical evidence of peritonitis, and a gastroduodenogram documented a sealed perforation. The ulcer was believed to be acute in 27 patients and chronic in 8. These 35 cases represent 12% of 294 cases of duodenal and prepyloric peptic ulcers with perforation treated during the same period. An intra-abdominal abscess developed in 1 of the 35 patients. Reperforation did not occur. The mortality rate for the 259 cases treated operatively during this period was 6.2%; the mortality rate of the 35 cases treated nonoperatively was 3%. Duodenal ulcer can be safely treated nonoperatively when a gastroduodenogram documents self-sealing.     

Laparoscopic repair of perforated duodenal ulcer

Background: A series of 100 consecutive patients with perforated peptic ulcer were prospectively evaluated in a multicenter study. The feasibility of the laparoscopic repair was evaluated. Methods: All patients had peritonitis, 20% were in septic shock, and 57% had delayed perforation. Conversion to laparotomy was necessary in eight patients. The morbidity rate was 9% and mortality rate 5%. Results: The mean delay of postoperative gastric aspiration (mean 3.4 days) and resumed food intake (mean 4.4 days) as well as the mean postoperative hospital stay (mean 9.3 days) were comparable to conventional surgery, but postoperative comfort was subjectively increased by laparoscopy and noticed by all laparoscopic surgeons participating in this study. Conclusions: Laparoscopic repair of perforated peptic ulcer proves to be technically feasable and carries an acceptable morbidity and mortality rate, compared with conventional surgery. Received: 16 August 1996/Accepted: 1 April 1997     

Outcome of omentopexy as primary repair in perforated duodenal ulcer

Objective: This study was conducted to determine the short-term complications and duration of hospital stay in patients treated with omentopexy as primary repair in perforated duodenal ulcer that were more than 12 hours old and more than 0.5 cm in size. Study Design: Case-series study. Place and Duration of Study: Department of General Surgery, Bolan Medical College, Quetta from January 2006 to January 2007. Patients and Methods: Thirty consecutive patients of perforated duodenal ulcer in whom the duration of perforation was greater than 12 hours and size of perforation was greater than 0.5 cm were included in this study. After adequate resuscitation, emergency laparotomy was performed and primary repair with pedicled omental patch performed without primary suturing of the perforation. A thorough peritoneal lavage was done with normal saline. Postoperatively, all the patients were given intravenous fluids, antibiotics and H2-receptor blockers. All the patients were closely monitored for the development of any postoperative complication. All the findings were recorded on a pre-designed proforma. Duration of hospital stay was noted at the time of discharge. All the patients were discharged on proton pump inhibitors, prescribed for 6 weeks. Results: Perforation was present on the anterior surface of the first part of duodenum in all cases. Size of perforation varied from 0.6 cm to 1.5 cm. Median size was 0.8 cm. Wound infection was seen in 10 (33.3%) patients and pneumonia in 7 (23.3%) patients. Two (6.7%) patients developed burst abdomen and residual pelvic collection that required re-operation. Overall, 15 (50%) patients did not develop any complication. Mortality was 1 (3.3%). Median hospital stay was 9 days. Conclusion: Omentopexy with thorough peritoneal lavage is simple and safe procedure with low mortality and fewer post-operative complications. It does not require great expertise and can be performed in a very short time in seriously ill patient. It should be chosen instead of an acid reducing operation in an emergency setting.     

Selective surgical management of perforated duodenal ulcer

In an effort to clarify the preoperative indications and factors predisposing to an increased operative morbidity for "definitive" ulcer procedures, the medical records of 114 patients with perforated duodenal ulcers were reviewed. One hundred nine patients underwent operation, with 55 patients treated with ulcer closure (Group 1) and 54 underwent a "definitive" operation (Group 2). Thirty-two complications developed in 27 patients (25%), with major infectious complications occurring in 9 per cent and 7.5 percent in the simple ulcer closure and definitive surgery groups, respectively. This study demonstrates that preoperative shock, operation delayed greater than 48 hours, and patient age greater than 60 years were significant factors increasing morbidity. The importance of peritoneal soilage and positive cultures are unreliable in predicting subsequent clinical infection and do not contraindicate definitive surgical management.     

Laparoscopic surgery of perforated duodenal ulcer]

BACKGROUND AND AIM: Endoscopic diagnostic and therapeutic possibilities have been increased by videolaparoscopy. The method enables an immediate reliable diagnosis to be made, associated with possible surgical treatment. METHODS: The authors report their laparoscopic experience relating to the treatment of perforated duodenal ulcer from 1972 to 1995 in 8 patients divided into two groups. Jacob Palmer's laparoscopic operator was used in the first group together with Menghini's needle for the aspiration of peritoneal effusion; the operation was performed under local anesthesia with nitrogen monoxide insufflation using Taylor's technique number I. The second group underwent ulcorrhaphy with omentopexy, again using a laparoscopic route, together with abundant lavage and accurate aspiration of fibrin. RESULTS: The patients in the first group made a prompt recovery in terms of their general conditions following the remission of fever, pain, diminished leukocytes and an early renewal of canalisation; cicatrisation of the ulcer was confirmed by the endoscopic control on day 15. Patients in the second group showed early deambulation approximately 4 hours after surgery; canalisation occurred after about 6 hours and all patients were discharged on day 3. The eradication of Helicobacter pylori led to complete resolution, as was confirmed by subsequent follow-ups. CONCLUSIONS: Laparoscopy was found to be extremely useful both in the immediate diagnosis of acute abdomen following perforated ulcer and in its surgical treatment as a result of the introduction of operating laparoscopes and in particular videolaparoscopes, together with surgical instruments that allow careful abdominal cleansing and ulcorrhaphy. In the authors' opinion, the latter procedure is the most suitable for managing this pathology.     

Endoscopic follow-up of the perforated duodenal ulcer

Since the introduction of cimetidine, multiple studies have documented that H2 antagonists will heal over 95 per cent of duodenal ulcers with 6 to 8 weeks of therapy. Despite this overall decline, it has been shown that the rate of complications from duodenal ulcers, specifically perforation, has remained virtually unchanged. A retrospective look at the perforated duodenal ulcers admitted to the Medical College of Georgia between 1978 and 1984 revealed a total of 45 patients with 39 survivors. Eighty per cent of the 39 underwent follow-up endoscopy in a period of 4 to 12 weeks after perforation. Twenty-six of these patients had been treated with omental patch and an average of 7.5 weeks of cimetidine. Sixty-five per cent of those treated with omental patch and cimetidine continued to have active ulcer disease on endoscopic follow-up. Twenty-three per cent were asymptomatic despite active disease. Perforation appears to represent the severest form in the spectrum of duodenal ulcer disease. H2 antagonists have been shown to heal over 90 per cent of duodenal ulcers with 8 weeks of therapy. This study reveals them to be less effective with the perforated ulcer. It is recommended that patients treated with omental patch and cimetidine be followed closely with endoscopy and be considered for longer medical therapy.