perforated peptic ulcers - department of surgery at · pdf fileng ek, lam yh, sung jj, et al....

Perforated peptic ulcers

Dr V. Roudnitsky

KCH

downstatesurgery.org

Peptic ulcer disease

• Peptic ulcers are focal defects in the gastric or duodenal mucosa that extend into the submucosa or deeper

• Caused by an imbalance between mucosal defenses and acid/peptic injury

• The costs of PUD, including lost work time and productivity, are estimated to be above $8 billion per year in the United States

• In the United States with a prevalence of about 2%, and a lifetime cumulative prevalence of about 10%, peaking around age 70 years


Helicobacter Pylori

• 50% of the world's population is infected with H. pylori• Only 10 to 15% of patients colonized with H. pylori will

develop PUD over their lifetime• HP possesses the enzyme urease:

– converts urea into ammonia and bicarbonate• The Bicarbonate buffers the acid secreted by the stomach. • The ammonia is damaging to the SECs

• Inhibitory effect on antral D cells that secrete somatostatin– No inhibition of antral G-cell gastrin production

• Local alkalinization of the antrum (antral acidification is the most potent antagonist to antral gastrin secretion)

• The end result is hypergastrinemia and acid hypersecretion


Other causative agents :

1. Drugs (all NSAIDs, aspirin, and cocaine)

2.Smoking

3.Alcohol

4.Psychologic stress.

In the United States, probably more than 90% of serious peptic ulcer complications can be attributed to H. pyloriinfection, NSAID use, and/or cigarette smoking.


Modified Johnson classification for gastric ulcerdownstatesurgery.org

The incidence of emergency surgery and the death rate associated with

peptic ulcers has not changed significantly for last few decades


SURGICAL COMPLICATIONS OF PEPTICULCER DISEASE

• Perforation

• Bleeding

• Gastric Outlet Obstruction

• Intractable disease


SURGICAL COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION

• Acute perforations of the duodenum are estimated to occur in 2% to 10% of patients with ulcers

• Surgery almost always indicated

• Conservative management should considered in patients who do not have :

– generalized peritonitis

– hemodynamic instability

– free peritoneal perforation on a Gastrografin upper gastrointestinal study



• Conservative management– serial physical and laboratory examinations – nasogastric suction– intravenous acid secretion suppression– intravenous broad-spectrum antibiotics

• In any time during conservative management the patient deteriorates, an operation is indicated

• Retrospective and prospective, randomized studies suggest that conservative management is effective in properly selected patients


Crofts TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperative treatment for perforated peptic ulcer. New Eng J Med 1989;320:970–973

Berne TV, Donovan AJ. Nonoperative treatment of perforated duodenal ulcer. Arch Surg 1989;124:830–832

Keane TE, Dillon B, Afdhal HH, et al. Conservative management of peforatedduodenal ulcer. Br J Surg 1988;75:583–584

Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: An alternative therapeutic plan. Arch Surg 1998;133:1166–1171

Marshall C, Ramaswamy P, Bergin FG, et al. Evaluation of a protocol for the nonoperative management of perforated peptic ulcer. Br J Surg 1999;86:131–134



• Appropriate surgical management of perforated ulcers remained controversial :– Simple patch ( laparoscopic or open) vs antiulcer

operation???


Cellan-Jones(1929) /Graham Patch(1937)


Comparison Between Open and Laparoscopic Repairof Perforated Peptic Ulcer Disease

World J Surg (2008) 32:2371–2374

• Prospective , non randomized study• August 2006-2007, 33 patient included, single institution• Laparoscopic patch 19, open Patch 14• The primary end points :

– total operative time– nasogastric tube utilisation– intravenous fluid requirement– total time of urinary catheter and abdominal drainage usage– return to normal diet– intravenous/intramuscular opiate– time to full mobilization– total in-patient hospital– stay.


Comparison Between Open and Laparoscopic Repairof Perforated Peptic Ulcer Disease

World J Surg (2008) 32:2371–2374


Presenter

Presentation Notes

NGtubes were removed when they were draining\200 ml per 24 hours. Abdominal drains were removed when output was\30 ml per 24 hours

Truncal Vagotomy

•The 2-cm length of ANTERIOR AND POSTERIOR nerve is resected

•Esophagus should be more widely mobilized for a distance of 4–5 cm above the gastroesophageal junction

•The "criminal nerve" of Grassi – origin from posterior vagus

•Frozen section should be requested to confirm vagotomy


Selective Vagotomy

Preserve:

•posteriorly derived vagalbranch that innervates the small intestine and pancreas

•anteriorly derived vagalbranch that supplies the gallbladder and liver

•involves interruption of both nerves of Latarget and therefore does not avoid the need for a drainage procedure


Highly Selective Vagotomy

Preserve:

•posteriorly derived vagalbranch that innervates the small intestine and pancreas

•anteriorly derived vagalbranch that supplies the gallbladder and liver

•both nerves of Latarget and therefore avoid the need for a drainage procedure


Drainage procedures( with TV or SV )

Heinecke-Mikuliczpyloroplasty

•Full-thickness incision extends from 2 cm proximal to 1–2 cm distal to the pyloric ring

•The incision is closed vertically

•Illustration of Gambee stitch


Drainage procedures

Finney U-shaped pyloroplasty

•The inverted U-shaped incision into the lumens of the stomach and duodenum

•Suture of the posterior septum of the stomach and duodenum

•The first anterior tier of sutures (Connell) is placed


Billrot 1 gastrectomy

Reconstruction:

A. Bilroth I

B. Horsley

C. Von Haberer-Finney

D. Von Haber

E. Shoemaker


Bilroth 2 gastrectomydownstatesurgery.org

Controlled tube duodenostomy in the management of giant duodenal ulcer perforation—a new technique for a surgically challenging conditionDepartment of Surgery, Maulana Azad Medical College (University of Delhi), and Associated LokNayak Hospital, New Delhi, IndiaThe American Journal of Surgery (2009) 198, 319–323


Procedure for type 4 gastric ulcer

• Pauchet procedure for ulcer > 2 cm from GE junction

• Csendes procedure for ulcer < 2 cm from GE junction.


Pre-operative risk scores for the prediction of outcome in elderlypeople who require emergency surgery

World Journal of Emergency Surgery 2007, 2:16


Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter pylori prevents recurrenceof ulcer after simple closure of duodenal ulcer perforation. Ann Surg.

2000;231:153-158.

• 129 patients with perforated DU• 104(81%) with positive HP• Surgery – simple patch• Randomization:

– HP therapy + PPI– PPI therapy alone

• 1 Year endoscopic evaluation for recurrent ulcer:– HP therapy group – 5% of recurrent ulcer– PPI group – 38%


Trends and Outcomes of Hospitalizations for Peptic Ulcer Diseasein the United States, 1993 to 2006

Ann Surg 2010;251: 51–58


Emerging Trends in Peptic Ulcer Disease andDamage Control Surgery in the H. pylori Era

From the Department of Surgery, Harbor-UCLA Medical Center, Torrance, CaliforniaTHE AMERICAN SURGEON September 2005


The management of large perforations of duodenal ulcersSanjay Gupta, Robin Kaushik*, Rajeev Sharma and Ashok Attri

BMC Surgery 2005, 5:15


Who is the Patient with PUD perforation who needs antiulcer surgery in 21 century?

• Failure of medical treatment ?

• Need for long term steroids or NSAIDs?

• Smokers /EtOH?

• Non compliant patients?

• Prepyloric and pyloric channel perforation?


Did HP treatment +PPI have been replaced antiulcer surgery???


perforated peptic ulcers - department of surgery at · pdf fileng ek, lam yh, sung jj, et al....

Documents