Laparoscopic correction of perforated peptic ulcer: first choice? A review of literature

Background  

Perforated peptic ulcer (PPU), despite antiulcer medication and Helicobacter eradication, is still the most common indication for emergency gastric surgery associated with high morbidity and mortality. Outcome might be improved by performing this procedure laparoscopically, but there is no consensus on whether the benefits of laparoscopic closure of perforated peptic ulcer outweigh the disadvantages such as prolonged surgery time and greater expense.     

Heterotopic gastric mucosa of the small bowel with perforated ulcer.

A patient with heterotopic gastric mucosa of the small intestine with perforation of the ileum due to ulceration of the adjacent mucosa is presented. Twelve symptomatic and six asymptomatic cases from the literature are reviewed. The majority of patients presented with intermittent obstruction due to intussusception of the ectopic gastric mass. Hemorrhage or chronic blood loss anemia occurred in the three patients in whom ulceration was present, and one of these patients had an intestinal perforation.     

Laparoscopic repair of perforated peptic ulcer: a meta-analysis

Background Laparoscopic repair of perforated peptic ulcer has been gaining popularity in recent years, but few data exist to support the superiority of the laparoscopic approach over open repair. The objective of the current study was to compare the safety and efficacy of open and laparoscopic repair of perforated peptic ulcer in an evidence-based approach using meta-analytical techniques.Methods A search of electronic databases, including MEDLINE and EMBASE, was conducted to identify relevant articles published between January 1990 and December 2002. Only studies in the English language comparing the outcomes of laparoscopic and open repair of perforated peptic ulcer were recruited. All reports were critically appraised with respect to their methodology and outcome. Data from all included studies were extracted using standardized data extraction forms developed a priori. Both qualitative and quantitative statistical analyses were performed. The effect size of outcome parameters was estimated by odds ratio where feasible and appropriate.Results A total of 13 publications comprising 658 patients met the inclusion criteria. The overall success rate of laparoscopic repair was 84.7% (n = 249). Postoperative pain was lower after laparoscopic repair than after open repair, supported by a significant reduction in postoperative analgesic requirement after laparoscopic repair. Meta-analyses demonstrated a significant reduction in the wound infection rate after laparoscopic repair, as compared with open repair, but a significantly higher reoperation rate was observed after laparoscopic repair.Conclusions Evidence suggests that laparoscopic repair of perforated peptic ulcer confers superior short-term benefits in terms of postoperative pain and wound morbidity. This approach is as safe and effective as open repair. Laparoscopic Graham–Steele patch repair of perforated duodenal or justapyloric ulcer is beneficial for patients without Boeys risk factors.     

Laparoscopic treatment of perforated peptic ulcer

STUDY OBJECTIVE: Contribution to evaluation of the place of laparoscopic surgery in the treatment of perforated peptic ulcer. PATIENTS AND METHODS: Between January 1992 and November 1997. 17 consecutive patients underwent laparoscopic suture of a perforated peptic ulcer, with or without omentoplasty. RESULTS: Treatment was performed entirely by laparoscopy in 13 cases (76%). The median operating time was 105 min (50-220 min). The median number of doses of analgesia administered to each patient was 8 (3-20 doses). The medium hospital stay was 6 days (2-23 days). Two patients (12%) died. In 11 cases, gastroscopy was performed between 1 and 4 months after the operation, revealing healing of the ulcer in 10 cases and persistence of the ulcer in one case. None of the patients were readmitted to hospital for ulcer complications, with a median follow-up of 35 months (1-63 months). CONCLUSION: The laparoscopic treatment of perforated duodenal is a technically simple and effective procedure, intermediate between conventional surgical treatment and Taylor's method. Laparoscopic surgery may therefore have a real place in the treatment of perforated peptic ulcer.     

Systematic review comparing laparoscopic and open repair for perforated peptic ulcer

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 the Medline/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.     

Laparoscopic suture closure of perforated peptic ulcer

Background: Laparoscopic vs open suture in the surgical treatment of perforated peptic ulcer were compared in a retrospective study. Methods: The outcome of 10 patients having the laparoscopic procedure was compared with the outcome of 17 patients treated with suture via laparotomy during the same time period. Results: The mortality rate and the complication rate were comparable. The laparoscopic procedure was more time consuming; hospital stay did not differ. Conclusions: The results indicate that surgery for perforated peptic ulcer can be performed with the laparoscopic technique with an outcome comparable to open surgery. No obvious advantages to the patient were noted with the laparoscopic method.This study has been presented as an abstract at the EAES meeting in Madrid, September 1994     

Laparoscopic repair of perforated peptic ulcer: single-center results

Background

Perforated peptic ulcer (PPU), the most common indication for emergency gastric surgery, is associated with high morbidity and mortality rates. Outcomes might be improved by performing this procedure laparoscopically, but no consensus exists on whether the benefits of laparoscopic repair (LR) of PPU outweigh the disadvantages.

Methods

From January 2002 to December 2012, 111 patients underwent surgery for perforated ulcer. A “laparoscopy-first” policy was attempted and then applied for 56 patients. The exclusion criteria for LR ruled out patients who had shock at admission, severe cardiorespiratory comorbidities, or a history of supramesocolic surgery. The aim of this study was a retrospective analysis of the 56 patients treated laparoscopically.

Results

The patient distribution was 30 men and 26 women, who had a mean age of 59 years (range 19–95 years). The mean ulcer size was 10 mm, and the Mannheim peritonitis index (MPI) was 21. LR was performed for 39 (69.6 %) of the 56 patients and included peritoneal lavage, suturing of the perforation, and omental patching. Conversion to laparotomy was necessary in 17 cases (30.4 %). The “conversion group” showed significant differences in ulcer size (larger ulcers: 1.9 vs 0.7 mm; p < 0.01), ulcer-site topography (higher incidence of posterior ulcers: 5 vs 0; p < 0.01), and MPI score (higher score: 24 vs 20; p < 0.05). The LR group had a mean operating time of 86 min (range 50–125 min), an in-hospital morbidity rate of 7.6 %, a mortality rate of 2.5 %, and a mean hospital stay of 6.7 days (range 5–12 days). None of these patients required reintervention.

Conclusions

The results showed that LR for PPU is feasible with acceptable mortality and morbidity rates. Skill in laparoscopic abdominal emergencies is required. Perforations 1.5 cm or larger, posterior duodenal ulcers, and an MPI higher than 25 should be considered the main risk factors for conversion.     

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.