Laparoscopic management of perforated peptic ulcer using combined suturing and fibrin glue patch

Laparoscopic management of perforated peptic ulcer using combined suturing and fibrin glue patch

Magdy  Bassiouny,MD; Ahmed  H Abdelhafez,MD; Salah M Raslan,MD; Ashraf  Hegab,MD; Mohammed Saif, MD; Gamal Fawzy,MD

Ain Shams University, Cairo, Egypt.

Abstract

Background: Duodenal perforation is a common complication of duodenal ulcer. Treatment for perforated peptic ulcer can be performed by laparoscopy in 85% of cases, making it possible to avoid a median laparotomy  which can lead to wound infection and late incisional hernia.

Methods: Twenty-four patients  with perforated  peptic  ulcer  were planned  to be treated laproscopically,  three of whom were excluded from the study (one patient with previous upper abdominal operations, one with bleeding peptic ulcer and the third one had evidence of gastric outlet obstruction).The study started.from January 2009 till December 2010.Five patients were operated in Ain Shams University hospitals  (Egypt) and sixteen patients were operated upon in Kingdom of Saudi Arabia. Mean age was (38.1±10.3), diagnosis of perforated peptic ulcer was reached usual by clinical examination, laboratory investigations, plain X-ray chest, abdomen and abdominal U/S. One case was misdiagnosed originally as acute appendicitis.All operations were performed  by laparoscopy; closing  the perforation with intra-corporeal sutures  and application of fibrin glue patch.

Results: Mean  operating time was 65 minutes. All procedures included  suturing  of the perforation with application of fibrin glue patch with peritoneal toilet and suction drain.Mean hospital stay was 3.5days. All patients had no serious postoperative complications apart from three patients, two of them developed chest infection and the third patient had postoperative leak and peritonitis.

Conclusion: Laparoscopic  closure of peptic ulcer is safe with short hospital stay and early return to work.

Key words: Peptic ulcer, perforation, fibrin glue patch and laparoscopy.

Introduction:

Perforated peptic ulcer is mainly a disease of young  men but because of increasing smoking in women and use ofNSAID in all age groups, nowadays it is common in all adult population. Up to 80% of perforated duodenal ulcers are  Helicobacter pylori positive. 1

The treatment of peptic ulcer disease (PUD) that involves duodenal bulb and prepyloric ulcers continue to evolve because of recent advances in pharmacology, bacteriology, and operative techniques. The first major change occurred after the introduction ofH2-receptor antagonists for gastric acid suppression in the

1970s, followed by proton pump inhibitors in

the late 1980s. In addition, the discovery that

Helicobacter pylori  is present in 75-85%  of these patients revolutionized the pathophysiologic understanding of peptic ulcer disease.2 Since the first description of surgery for acute perforated peptic ulcer disease, many techniques have been recommended like hand suturing the edges of the wound, stapling, omental patch and closing the perforations with fibrin sealant and gelatine plug products.3

Laparoscopic surgery  has revolutionized the practice of cholecystectomy and has led to

the  development of  a wide  range of laparoscopic surgical procedures. Progress currently can be said to include this minimally invasive surgical procedure for  perforated peptic ulcer.4

Treatment  for perforated ulcer can be performed laparoscopically in 85% of cases, making it possible to avoid  a median laparotomy which can lead to wound infection and late incisional hernia.Laparoscopic repair of duodenal perforation with combined suturing and fibrin glue is a useful method for reducing hospital stay, complications and return to normal activity.I

Patients and methods:

Twenty-one patients treated with laparoscopic suturing of perforated peptic ulcer with fibrin glue patch over it .The study started from January 2009 till December 2010. Five patients were operated on in Ain Shams University hospitals  (Egypt) and sixteen patients were operated on inKingdom of Saudi Arabia.

Operative technique:

The patient is placed in supine position with

legs straight. The patient position is changed several times during the procedure: in steep anti-Trendelenburg position during suturing and in the right lateral position and head down position during peritoneal lavage.

Endotracheal anaesthesia is generally used. Close anaesthetic monitoring must be done for such a patient and intravenous antibiotic therapy should be given before induction. An H2 receptor antagonist or a proton pump inhibitor injection was used.

The surgical team stands as for laparoscopic

cholecystectomy. The surgeon stands on the patient's left side and the assistant  to the patienes right.  The camera  man on the surgeon's left side.

The laparoscopic unit  is placed  on the patient's right side toward the shoulder. The instrument table is placed beside the patient's right leg.

Four trocars have been used. An optical trocar of 10 mm is introduced in the periumbilical region. One trocar of 5 mm is placed in the inferior aspect of the right hypochondrium on the anterior axillary line for liver retraction with a traumatic grasper. A 10 mm trocar is placed in the epigastrium for the needle holder. A fourth trocar of 5 mm is placed at the level of the umbilicus in the midclavicular line. The instruments are similar to those used in most laparoscopic procedures. A 0° laparoscope is commonly used, but a 30° laparoscope may be useful to see better a perforated ulcer placed on the superior surface of the duodenum. The other instruments necessary for this operation are: 2 atraumatic graspers, needle holder, suction-irrigation device, and scissors. A liver retractor was used in   some   cases  instead  of   a  grasper.

The Veress needle technique was used. The abdomen was entered through a small incision just  above  the  umbilicus. A  C02 intra­ abdominal pressure between 12 and 14 mmHg was used. The scope was inserted through the

10 mm trocar placed in the supra-umbilical position. Once the diagnosis was confirmed the other three ports were placed as mentioned above. Bacteriological samples were taken and sent immediately to the laboratory. The abdomen was explored to identify the perforation and to assess the magnitude of peritonitis.  The gallbladder,  which usually adheres to the perforation was retracted by the surgeon's left instrument and moved upwards. The gallbladder was passed to the assistant using the instrument  placed in the inferior aspect of the right hypochondrium on the anterior axillary line. Once the liver was retracted, the exposed area was carefully checked and the perforation was usually clearly identified as a small hole on the anterior aspect of the first portion of the duodenum Figure(l).

Figure (1): Perforated duodenal peptic ulcer identified through laparoscopy

Next  step was  peritoneal toilet. The subhepatic and subphrenic spaces were irrigated and  aspirated with  warm  saline solution. Fibrinous membranes were removed as much as possible. Once the abdominal  cavity was clean the  attention was  returned to the perforation. Biopsy of a duodenal  ulcer was

not necessary. However, for a prepyloric ulcer, samples of the gastric wall at the level of the perforation were taken and sent for histological examination. Suturing was done with 2/0 or

3/0 absorbable sutures

Figure(l).

Figure (2): Suture of the perforation using standard stitches

Interrupted sutures were used and usually two or three stitches were placed ina transversal manner over the perforatifocused on the pyloroduodenal axis in case of a duodenal

ulcer.Once the perforation was sealed, a small sheet of fibrin glue patch was fixed over the suture line.Figure(3)A,B

=-

Figure (3)A: Fixation of the fibrin glue over the site of  perforation after suturing.

The peritoneal lavage was continued after suturing. Warm saline solution was used until the returned liquid was clear. About fomlitres of saline are generally used.

Figure (3)B: Fibrin glueafter fiXation.

Routine drainage of the peritoneal cavity was performed using suction drain (18 French) in the subhepatic region coming out via the trocar site situated on the right flank Figure(4).

Figure (4): 18 French suction drain placed in subhepatic space.

Finally the ttocars were removed one after the other and haemostasis of the trocar sites was checked.The scope was removed leaving the gas valve of umbilical port open to let out all the gas. The anterior rectus sheath was closed at the site of the 10 nun trocar sites. The skin was closed using staples or sutures.

Produtt details:

Fibrin glue patch is a ready-to-use surgical patch that allows haem.ostasis and tissue sealing to be achieved quickly and easily.It is a fixed

combination of a patch sponge coated with a dry layer of the human coagulation factors fibrinogen and  thrombin. It achieves haemostasis and sealing in 3-5 minutes and has several distinct advantages compared with current supportive techni.ques.s

Fibrin  glue patch has strong  adhesive properties in all body fluids, creating an air­

and liquid-tight seal. It is truly ready-to-use as it needs no preparationo reconditioning and no thawing prior to application.

It is physiologically extensible and pliable,

allowing it to follow the movement of organs freely and easily.5 It is enzymatically degraded and safely absorbed by the body within twelve weeks of application. It can be applied in surgical areas that are difficult to access.6 It allows compression to be applied to the tissue.6

Postoperative management:

Intravenous H2 receptor antagonists or proton  pump  inhibitors (PPis)  are  given intravenously and then orally once oral feeding is started after assurance ofbowel movement. Intravenous antibiotic therapy is maintained depending on the severity of the peritonitis and at least until a culture of the peritoneal fluid taken during the procedure is obtained. The aims of antibiotic therapy are to combat peritonitis and Helicobacter pylori.  The nasogastric tube is removed once peristalsis resumes. Food intake is then restored. Drains are removed once the effluent is less than 50ml

Table (l):Perioperative criteria.

per day. Patients are usually discharged 3-4 days after operation.

Upper gastroduodenoscopy is performed usually  4 to 6 weeks after  the operation.

Statistical Analysis:

Data were collected on standard forms and were prospectively entered into a computer database. Preoperative data comprised characteristics of the patients, history, physical examination findings, laboratory and imaging tests and intra-operative criteria and postoperative period data and return to full activity were included.

Results:

From January2009  till December 2010,

twenty-one patients with  a preoperative diagnosis of perforated peptic ulcer treated laproscopically were entered final analysis.

The preoperative characteristics including the  demographic  data  of  the  patients: Mean  age  was  (38.1±10.3) and  sex distribution was eighteen males (85.7%) & three  females  (14.3%). Data  of  patient's presentation such as shock on admission was one case (0.48%), and two cases presented with epigastric pain duration longer than 24 hours(0.95%), and five patients were admitted with previous history of peptic ulcer disease

Table (1):Statistics of operative data.

(23.8%), and six  patients with  recent consumption of nonsteroidal anti-inflammatory drugs (28.57%) and ten patients gave a history of smoking (47.62%). According to American Society of Anaesthesiology (ASA) classification status was: Class I were ten cases (47.62%) & Class II were six cases (28.57%)

& Class III were four cases (19%) and Class

IV  were   one  case  (0.48%)   Table(l).

The mean operative time of laproscopic repair of perforated peptic ulcer ranged from

35 to 60 minutes (45±15.4). According to the sites and sizes of ulcer perforations were as

Table (3): Postoperative data.

follows: Duodenal ulcer in eighteen cases (85.7%) & prepyloric in three cases (14.3%). Mean size of ulcer perforations was 5.1 mm Table(2).

The characteristics of patient's postoperative data showed that patients required significantly less parenteral analgesics, lower visual analogue pain score on postoperative days 1 (3.5) and day 3(1.6). And the timing of removal of nasogastric tube was in the second or third

Table (4): Post operative complications.

postoperative day and four (3-5) days are the timing of full diet resumption and the hospital stay ranged from three to four days and the patient could return back to work about ten days after discharge Table(3).

Post  operative complications included 2 cases (0.95%) of chest infection one of them was known to have COPD and was managed by antibiotics and improved. The other  one was heavy  smoker and was treated with expectorants and third patient had postoperative leak and was reoperated laproscopically with deudenostomy tube and feeding jejunostomy (0.48%)  Table(4).

Discussion:

Advances in the medical treatment of peptic ulcer disease have led to a dramatic decrease in the  number of  elective ulcer  surgeries performed Nonetheless, the number of patients treated  surgically  for complications such as perforations remains relatively unchanged. 7

Laparoscopy has  assumed an  ever­ expanding role in gastrointestinal surgery since the introduction of laparoscopic cholecystectomy. Laparoscopic cholecystectomy has rapidly become a standard practice in most parts of the world for elective cholecystectomy, but the role oflaparoscopy in perforated peptic ulcer was not well defined.8

Actually, using laparoscopy for treatment of perforated peptic ulcer includes; Graham­ Steele patch repair, suture closure with an omental patch and simple closure without omental  patch.  The procedure is relatively simple but requires the ability to perform an intra-corporeal knot. The application of fibrin glue patch reinforces the sutures and avoid the need to applicate an omental patch and make the procedure faster and easier.

Boey et, al. reported  that major medical illness, preoperative shock, and longstanding perforation (more than  24 hours) were considered poor  prognostic factors.  In this study, we found  that hypotension could not reliably predict outcome, and  all  patients admitted  with  hypotension  survived.9

G.Piero et al. reported that published data

comparing laparoscopic and open repair for perforated peptic  ulcers  report  lower  post operative analgesic use, lower wound infection and mortality, fewer incisional hernias with laparoscopy but longer  operating time and higher reoperation rate.lo

In our experience laparoscopic repair using fibrin glue  patch was  performed under

supervision of expert surgeons and the results in terms of duration of surgical procedure was short (45±15.4 min.) and clinical outcome was satisfactory. We have single case of postoperative leak  which  was  re-operated laproscopically.

Conclusion:

The medical  treatment of peptic  ulcer is highly successful. In addition eradication of Helicobacter  pylori reduces ulcer recurrence.

The non-operative treatment of perforated

peptic ulcer was first described by Tylor  in

1945. However this kind of treatment modality is  suitable for younger patients, heamodynamically stable and  the  disease history less than twelve hours, therefore most surgeons treat perforated peptic ulcer surgically.

Laparoscopy provides good visualization of the peritoneal cavity without necessity to do laparotomy for a relatively simple procedure.

Accordingly we have switched our treatment to laparoscopic simple closure of the perforation site   combined with  fibrin  glue   patch.

Laparoscopic suturing of perforated peptic ulcer  combined with  fibrin glue  patch  is associated  with minimal postoperative pain, short  duration of postoperative ileus, early resumption of normal  diet, early  discharge from hospital and early back to work and full activity.

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2010; 18(2): 87-90.

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