ACUTE CARE; WHAT IS THE

PLACE OF LAPAROSCOPY?

‘’ Duodenal ulcer perforation’’ Korhan Taviloglu, MD

Department of Surgery Florence Nightingale Hospital,

Istanbul, Turkey www.taviloglu.com

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2 Hermansson M, et al. BMC Gastroenterology, 2009.

3 Hermansson M, et al. BMC Gastroenterology, 2009.

•  PPI’s •  Smoking habits •  NSAID

consumption •  Prevalence of H.

pylori

Duodenal ulcer perforation incidence decreases

Peptic ulcer perforation changes in localization among years

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Wysocki A, et al. World J Surg, 2011

Duodenal ulcer perforation changes in gender & age among years

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6 Manfredini R, et al. BMC Gastroenterology 2010,

Perforated ulcer: common problem

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Wong CH, et al. Surgery 2004.

Laparoscopy for duodenal perforation - History

•  1990: Mouret et al. first performed laparoscopic sutureless fibrin glue omental patch (Br J Surg)

•  1990: Nanthanson et al. first described a successful suture repair (Surg Endosc)

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Perforated ulcer: repair techniques

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Bertleff MJOE, et al. JSLS 2009

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Rosen MJ, Ponsky JR. Atlas of Surgical Techniques for the Upper Gastrointestinal Tract and Small Bowel, 2010.

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Atlas of Gastroenterology. Yamada T, 2009.

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Perforated ulcer: laparoscopic repair risk factors

14 Lunevicius R, et al. World J Surg 2005

Perforated ulcer: laparoscopic repair conversion – failure of laparoscopic repair

15 Lunevicius R, et al. World J Surg 2005

Perforated ulcer: laparoscopic repair conversion – failure of laparoscopy

16 Lunevicius R, et al. World J Surg 2005

Perforated ulcer: laparoscopic repair postoperative morbidity

17 Lunevicius R, et al. World J Surg 2005

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1st author Year Repair technique

Conclusion

Sunderland Hong Kong

1992 Omentopexy An alternative to open repair; performed easily by surgeons familiar with laparoscopic cholecystectomy

Munro UK

1996 Suture repair + falciform L patch

Safe; less pain; falciform ligament is an excellent, simple alternative to omentum

So Singapore

1996 Stapled omentopexy

Laparoscopic repair has no advantages; conversion is by ulcer location rather than size

Naesgaard Norway

1999 Suture repair with omentopexy

safe; increased mortality after prologed perforation

Perforated ulcer: laparoscopic repair results

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1st author Year Repair technique

Conclusion

Bergamaschi Norway

1999 Suture repair with omentopexy

Laparoscopic repair has no advantages; conversion is by ulcer location rather than size

Agresta Italy 2000 Suture repair

Laparoscopic repair is safe; risk factors: old age, shock, delayed peritonitis, ass. medical illness

Lee Hong-Kong

2001 Sutureless fibrin glue

APACHE II predicts morb. & mort. Boey score predicts mort. and conversion rate

Seiling Germany

2003 Suture repair Laparoscopic repair is safe and effective

Perforated ulcer: laparoscopic repair results

Comparison of laparoscopic suture & suture + omentoplasty

20 Hung-Chieh Lo, et al. World J Surg, 2011

Comparison of laparoscopic suture & suture + omentoplasty

21 Hung-Chieh Lo, et al. World J Surg, 2011

Perforated ulcer: Benefits of laparoscopic repair – meta-analysis

•  Lower postoperative analgesic use •  Lower wound infection •  Lower mortality •  Better cosmesis •  Shorter posoperative length of stay •  Fewer postoperative adhesions •  Fewer incisional hernias

22 Lau H. Surg Endosc 2004.

Perforated ulcer: Limitations of laparoscopic repair - meta-analysis

•  Higher reoperation rates •  Longer operating time: in many studies;

however, a randomized prospective study performed by Siu et al. (Ann Surg 2002) revealed that the OT is less: contributing factors

1.  Development of modern irrigation systems 2.  Increase in surgeons experience Katkhouda et al (Arch Surg 1999) Mehendale et al, Indian J Gastroenterol 2002 & other studies also supported these results.

23 Lau H. Surg Endosc 2004.

Laparoscopic repair of perforated ulcer: CONCLUSIONS

•  Laparoscopic repair is the procedure of choice in patients with no Boey risk factors.

•  Boey risk factors—shock, delayed presentation > 24 hours, underlying medical illness, elderly age (> 70 years)—must be considered as preoperative risk factors

•  Inadequate ulcer localization, large perforation size (some > 6 mm & others >10 mm), and fragile ulcer edges should be considered risk factors.

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Laparoscopic repair of perforated ulcer: CONCLUSIONS

•  Meticulous irrigation of the peritoneal cavity is necessary to prevent form infectious complications & prolonged ileus.

•  Laparoscopic sutureless fibrin glue repair should have strict patient selection criteria; otherwise morbidity approaches high rates (6–25%), although the mortality remains the same (3–8%).

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THANK YOU!! Korhan Taviloglu, MD

Department of Surgery Florence Nightingale Hospital,

Istanbul, Turkey www.taviloglu.com

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