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Perforated peptic ulcer

Laparoscopic treatment of perforated peptic ulcer Johan Lange Dep Surgery Erasmus University Medical Center Rotterdam. Perforated peptic ulcer. Perforated peptic ulcer famous fatalities. Rudolph Valentino. James Joyce. Napoleon. Perforated peptic ulcer Acute abdomen (De Dombal n=30.000).

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Perforated peptic ulcer

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  1. Laparoscopic treatment of perforated peptic ulcerJohan LangeDep Surgery Erasmus University Medical Center Rotterdam

  2. Perforated peptic ulcer

  3. Perforated peptic ulcerfamous fatalities Rudolph Valentino James Joyce Napoleon

  4. 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%

  5. Perforated peptic ulcerPathology • Most often chronic ulcer • 50%: sealed off • Location: most often anterior juxtapyloric • Mean diameter: 5mm (>1cm=giant ulcer: rare) • 10%: perforated gastric ulcer)

  6. Perforated peptic ulcermorphology related to location juxta-pyloric ulcer: small, healthy border gastric ulcer at lesser curvature: large, fibrotic edematous border (ulcus callosum)

  7. Perforated peptic ulcerperforated gastric carcinoma

  8. Perforated peptic ulcersealing off by left liver half

  9. Perforated peptic ulcersealing off by segment IV

  10. Perforated peptic ulcersealing off by left liver lobe X: free air below diaphragm in this patient

  11. Perforated peptic ulcerfibrinous peritonitis+parahepatic collection

  12. Perforated peptic ulcerulcer visible after lifting left liver lobe

  13. Perforated peptic ulcerBacteriology • <48h in 50%: sterile peritonitis; in other 50%: grampositive peritonitis • >48h: infected peritonitis, most often grampositive initially, later gramnegative

  14. Perforated peptic ulcercause of death: peritonitis Pre-antibiotics-mortality: 75%

  15. Perforated peptic ulcersubphrenisch abces

  16. Perforated peptic ulcerBoey prognostic parameters • Age • Duration of symptoms • Shock • ASA III-IV • Diameter of ulcer

  17. Perforated peptic ulcerDiagnosis

  18. Perforated peptic ulcerDiagnosis

  19. Perforated peptic ulcer

  20. Perforated peptic ulcer

  21. Perforated peptic ulcerDiagnosis • 1) X-thorax/abdomen in upright position • If negative: • 2) CT with oral contrast

  22. Perforated peptic ulcerduration of postoperative pneumoperitoneum • X: <6 days: 90% • CT: <6 days: 50%; <18 days: 100%

  23. Perforated peptic ulcerOperative therapy (history) • 1892 resection: Heusner • 1894 oversewe: Dean • 1937 omental patch: Graham • 1990 laparoscopy: Mouret (1947 Taylor: conservative)

  24. Perforated peptic ulcerOperative therapy (closure+lavage) • Only after resuscitation • Closure+lavage • Postoperative gastric aspiration • Acid suppression (PPI’ s) • Antibiotics

  25. Perforated peptic ulcerlaparoscopic closure

  26. Perforated peptic ulcerlaparoscopic closure

  27. Perforated peptic ulcer(stapler-fixation of omentum)

  28. Perforated peptic ulcerrendez vous omental patch

  29. Perforated peptic ulcerGraham 1937: omental patch plication (without primary closure of ulcer)Kathkouda et al 1993: laparoscopic Graham omental patch

  30. Perforated peptic ulcer3 stitch-Graham omental patch Distance ulcer>1cm Lam et al. Surg Endosc 2005; 19: 1627-30

  31. Perforated peptic ulcer3 stitch-Graham omental patch

  32. Perforated peptic ulcer Flat tire test

  33. Perforated peptic ulcerdrain?

  34. Perforated peptic ulceroperative therapy: abdominal complications • Re-leakage: 10% • Intra-abdominal abscess: 3%

  35. 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

  36. Management strategies, early results, benefits, and risk factors of laparoscopic repair of perforated peptic ulcer.Lunevicius R, Morkevicius M. • World J Surg 2005; 29: 1299-3102nd 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. rlunevichus@yahoo.comThe 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 goal was 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 were the 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.

  37. Systematic review comparing laparoscopic and open repair for perforated peptic ulcer.Lunevicius R, Morkevicius M. Br J Surg 2005; 92: 1195-207Clinic of General and Plastic surgery, Orthopaedics and Trauma surgery, General Surgery Centre, Vilnius University Emergency Hospital, 29 Siltnamiu Street, LT-04130, Vilnius, Lithuania. rlunevichus@yahoo.comBACKGROUND: 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.

  38. Perforated peptic ulceropen closure in the morbid obese

  39. Perforated peptic ulcerfree intraperitoneal air-differential diagnosis • Perforated peptic ulcer • Perforated diverticulitis • Perforated appendicitis • Perforated Crohn disease • Heimlich maneuver/Boerhaave syndrome • Through salpinx • Idiopathic

  40. Perforated peptic ulcerLAMA-trial: open vs laparoscopic closure (Marietta Bertleff)Raw data

  41. Perforated peptic ulcerexclusion of gastric carcinoma and helicobacter

  42. Perforated peptic ulcerremaining questions • Best technique of closure? • Postoperative gastric aspiration?

  43. Perforated peptic ulcer

  44. Perforated peptic ulcer Tissue glue

  45. Perforated peptic ulcerStamp method Bertleff M et al. Surg Endosc 2006 in press

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