Perforated peptic ulcers. Dr V. Roudnitsky KCH

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1 Perforated peptic ulcers Dr V. Roudnitsky KCH

2 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

3

4 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

5

6 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. pylori infection, NSAID use, and/or cigarette smoking.

7 Modified Johnson classification for gastric ulcer

8 The incidence of emergency surgery and the death rate associated with peptic ulcers has not changed significantly for last few decades

9 SURGICAL COMPLICATIONS OF PEPTIC ULCER DISEASE Perforation Bleeding Gastric Outlet Obstruction Intractable disease

10 SURGICAL COMPLICATIONS OF PEPTIC ULCER 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

11 SURGICAL COMPLICATIONS OF PEPTIC ULCER DISEASE : PERFORATION 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

12 Crofts TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperative treatment for perforated peptic ulcer. New Eng J Med 1989;320: Berne TV, Donovan AJ. Nonoperative treatment of perforated duodenal ulcer. Arch Surg 1989;124: Keane TE, Dillon B, Afdhal HH, et al. Conservative management of peforated duodenal ulcer. Br J Surg 1988;75: Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: An alternative therapeutic plan. Arch Surg 1998;133: 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:

13 SURGICAL COMPLICATIONS OF PEPTIC ULCER DISEASE : PERFORATION Appropriate surgical management of perforated ulcers remained controversial : Simple patch ( laparoscopic or open) vs antiulcer operation???

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

15 Comparison Between Open and Laparoscopic Repair of Perforated Peptic Ulcer Disease World J Surg (2008) 32: Prospective, non randomized study August , 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.

16 Comparison Between Open and Laparoscopic Repair of Perforated Peptic Ulcer Disease World J Surg (2008) 32:

17 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

18 Selective Vagotomy Preserve: posteriorly derived vagal branch that innervates the small intestine and pancreas anteriorly derived vagal branch that supplies the gallbladder and liver involves interruption of both nerves of Latarget and therefore does not avoid the need for a drainage procedure

19 Highly Selective Vagotomy Preserve: posteriorly derived vagal branch that innervates the small intestine and pancreas anteriorly derived vagal branch that supplies the gallbladder and liver both nerves of Latarget and therefore avoid the need for a drainage procedure

20 Drainage procedures ( with TV or SV ) Heinecke-Mikulicz pyloroplasty 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

21 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

22 Billrot 1 gastrectomy Reconstruction: A. Bilroth I B. Horsley C. Von Haberer-Finney D. Von Haber E. Shoemaker

23 Bilroth 2 gastrectomy

24 Controlled tube duodenostomy in the management of giant duodenal ulcer perforation a new technique for a surgically challenging condition Department of Surgery, Maulana Azad Medical College (University of Delhi), and Associated Lok Nayak Hospital, New Delhi, India The American Journal of Surgery (2009) 198,

25 Procedure for type 4 gastric ulcer Pauchet procedure for ulcer > 2 cm from GE junction Csendes procedure for ulcer < 2 cm from GE junction.

26

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28 Pre-operative risk scores for the prediction of outcome in elderly people who require emergency surgery World Journal of Emergency Surgery 2007, 2:16

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30 Ng EK, Lam YH, Sung JJ, et al. Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation. Ann Surg. 2000;231: 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%

31 Trends and Outcomes of Hospitalizations for Peptic Ulcer Disease in the United States, 1993 to 2006 Ann Surg 2010;251: 51 58

32 Trends and Outcomes of Hospitalizations for Peptic Ulcer Disease in the United States, 1993 to 2006 Ann Surg 2010;251: 51 58

33 Trends and Outcomes of Hospitalizations for Peptic Ulcer Disease in the United States, 1993 to 2006 Ann Surg 2010;251: 51 58

34 Emerging Trends in Peptic Ulcer Disease and Damage Control Surgery in the H. pylori Era From the Department of Surgery, Harbor-UCLA Medical Center, Torrance, California THE AMERICAN SURGEON September 2005

35 The management of large perforations of duodenal ulcers Sanjay Gupta, Robin Kaushik*, Rajeev Sharma and Ashok Attri BMC Surgery 2005, 5:15

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37 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?

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

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