Laparoscopic repair of perforated peptic ulcer: A prospective study

Laparoscopic repair of perforated peptic ulcer: A prospective study

Tamer A EIBakary,MD

Department of General Surgery, Tanta University Hospital, Tanta, Egypt.

Abstract

Background: Perforated peptic ulcer is a common surgical emergency. Its classic treatment is the mid-line laparotomy. However, laparoscopic treatment has been shown to be reliable. Few studies have evaluated its overall utility. The aim of this study is to assess the efficacy of laparoscopy in perforated peptic ulcer repair.

Patients and methods: The study included 18 patients presented by perforated peptic ulcer between July 2009 and December 2011. They were submitted to laparoscopic omental patch repair with thorough peritoneal wash. Patients' demographics, diagnostic techniques, management, and outcome were evaluated.

Results: The mean age was 35.6 years. Male to female ratio was 14:4. The mean duration

of symptoms was 18 hours. The perforation  was diagnosed by plain X-ray of the abdomen in erect position in 15 patients and by abdominal CT scan in 3 patients.The laparoscopic repair of the perforation  was successful  in 16 patients while in 2 patients mid-line laparotomy  was needed for proper control of the severe intra-abdominal sepsis. The mean operative time was

90 minutes. Post-operatively, the VAS score ranged between 3 and 6 with a mean of 3.5 in the first post-operative day. Narcotics were needed for a mean of 1.5 days. All the patients tolerated soft diet on the 3rd post-operative day and full diet on the 4th post-operative day. The mean duration of hospital stay was 4.5 days. One patient developed post-operative intra-abdominal collection  that was treated by ultrasound  guided drainage. One patient developed umbilical port  site wound  infection. No chest  infection, prolonged  ileus,  leakage, or mortality was encountered in the study.

Conclusion: Laparoscopic repair of perforated peptic ulcer is a safe and reliable technique

with accepted morbidity and mortality rates and all the advantages of the minimally  invasive surgery.

Key words: Laparoscopy, perforation, peptic ulcer, omental patch.

Introduction:

Peptic ulcer perforation is  a common surgical emergency. The  mortality rate  of patients with perforation ranges from 10% to

40%. So, immediate surgery is the treatment

of choice.l As the efficacy of gastric  anti­ secretory medication and  eradication of Helicobacter pylori has improved, the preferred surgical  technique for perforated duodenal ulcer treatmenthas been shifted from definitive ulcer surgery to primary repair of the perforation.2 In 1989, Mouret et ai3 performed the first laparoscopic perforated peptic ulcer

closure  using fibrin glue and omental patch. Then, Nathanson et al in 19904 described the first laparoscopic suture repair of perforated peptic ulcer. Since that time, laparoscopic repair of perforated peptic ulcer has gained more acceptance because it dose not only allow to identify the site and pathology of perforation, but it also allows closure  of the perforation and  peritoneal lavage  just like in the open repair but without the large upper abdominal incision and with  less  post-operative pain, faster recovery, and shorter  hospital  stay.5,6

Despite many trials, the upper laparotomy still

seems tobe the routine treatment of perforated peptic ulcer. So, we conducted this study to assess the efficacy of laparoscopic approach in perforated peptic ulcer repair.

Patients and methods:

Between  July 2009 and December  2011,

18 patients diagnosed with perforated  peptic ulcer were consented for laparoscopic repair of  the  perforation. All  the  patients were submitted to full history  taking,  laboratory investigations (complete blood count, liver &

kidney function tests, and serum electrolytes level), and plain X-ray of the abdomen in an erect position.Ifno free airwder the diaphragm was found in the plain X-ray, the patient was submitted to CT abdomen and  pelvis.  All patients were initially treated by intra-venous fluid resuscitation, naso-gastric tube insertion

for   gastric  decompression, parenteral analgesics, I.V. ranitidine 50 mg every  12 hours,  and I.V. antibiotics in the  form  of cefotaxime sodium 1 gm every 12 hours and me1ronidazole 500 mg every 8 hours. Informed consent was  taken from  all  patients for diagnostic laparoscopy and  laparoscopic perforated peptic ulcer repair with possibility of   conversion  to   open  laparotomy.

Exclusion criteria  in this study  included patients presented with  septic shock  and hemodynamic instability,  gastric ulcer

Figure (1): Taking the stitch through the edges

of the perforated duodenal ulcer.

perforation, history of  upper abdominal surgeries,and patients with symptoms duration more than 24 hours.

Once  the patient  was stabilized, surgery

was  done. Under general anesthesia with muscle relaxation, the patient was placed in Llyod-Davis' (French) position with reverse Trendelenberg tilt and the operating surgeon stood between  the patient's thighs. Ten mm port  was introduced through  a longitudinal supra-umbilical incision using the open teclmique. A 30 degrees scope was introduced through this port for abdominal  exploration and  confirmation of  the  duodenal ulcer perforation. Then, two 5-mm working  ports were introduced on the right  and left mid­ clavicular lines  just above  the level  of the umbilicus.

The first step was to do laparoscopic exploration to confirm  the diagnosis and to assess the degree of the peritoneal soiling. The pre-pyloric and the duodenal regions  were carefully inspected to localize the perforation, if omental reaction was found, the omentum was gently pulled away from the site of the perforation. Then, the perforation was repaired using intra-corporeal 3\0 polyglactin stitches Figure(!)that were  tied  over  a pedicled

omental patch  Figure(2,3). The number of stitches depended on the size of the perforation.

Figure (2): Intra-corporal  knotting of the stitch over   a  pedicled omental flap.

Figure (3): The final appearance of the repair.

Then, thorough peritoneal irrigation and suction of different abdominal compartments was done with special attention paid to sub­ phrenic,  sub-hepatic and  pelvic  regions

Figure (4): Irrigation and suction of the sub­

phrenic and sub-hepatic spaces.

At the end of the procedure, insuffi.ation of the stomach with 250ml of air was done to rule out any leak from the repair. Then, the incisions were closed. Duration of smgery was recorded from the time of skin incision to the time of skin closure.

Post-operatively, the patients were kept on parenteral narcotics (pethidine 50 mg 1Mevery

12 hours)for pain relief.Intmvenous antibiotics and ranitidine were continued for 5 days. We recorded the degree of post-operative pain by the Visual Analogue Scale (VAS) ranging from

0 (no pain) to 10 (severest pain) and by the number of days during which the patient was

Figure(4,5) and with obtaining samples of the intra-peritoneal fluid for cultures.An average of 6-8 liters of saline was needed to accomplish this irrigation.

Figure(5):Irrigationandsuctionofthepelvis.

in need for narcotics. The naso-gastric tube was removed on the second post-operative day and the oral feeding was started once the post­ operative ileus resolved.

Post-operative complications were recorded

in1he fotm of prolonged ileus,wound infection,

chest infection, intra-abdominal collections, leakage from the site of repair, and death. The patient was discharged once he tolerated oral diet, afebrile, and ambulant. Duration of hospital stay was calculated.

The patients were reviewed in the out-patient

clinic  at 2 weeks, 3 and 6 months post­

operatively.

All patients were  advised  to use proton pump inhibitors for 3 months with proper diet control and avoidance of smoking, NSAIDs, and alcohol.

Table (1): Patients demographics.

Results:

This study was conducted  on 18 patients who presented  by perforated  duodenal ulcer and they were treated by laparoscopic repair of the perforation. Patients' demographics are shown in Table(l).

The age of the patients ranged between 19 and 46 years with a mean of35.6 years. There were 14 males (77.8%) and4 females (22.2%). Three patients (16.7%) gave  history of symptoms suggestive of peptic ulcer disease. Nine patients (50%) were cigarette smokers and 5 patients (27.8%) were using NSAID for more than 2 weeks prior to the perforation. The duration of symptoms ranged between 4 and 24 hours with a mean duration of 18 hours. Inall the patients, plain X-ray of the abdomen in erect position was done. It showed free air under the diaphragm in 15 patients (83.3%). Inthe other 3 patients (16.7%), no fee air under the diaphragm was seen in the plain X-ray. So, CT scan  of the  abdomen was  done  and  it showed free intra- peritoneal air.

Intra-operatively, all the patients  showed intra-abdominal free fluid that ranged between greenish  bilious  fluid to purulent  fluid with pyogenic membranes covering the bowel and the intra-abdominal viscera according to the duration of the perforation.

Meticulous irrigation and suction was done for all the intra-abdominal compartments and between the bowel loops. Major part of the operative time was spent for this peritoneal wash.In2 patients, there was marked technical difficulty to control the intra-abdominal soiling with food particles and bowel adhesions. So, laparoscopic peritoneal toilet was inadequate. Midline laparotomy was done for proper control of the intra-abdominal soiling inthese 2 patients

with closure of the perforation over an omental patch. So, laparoscopic repair of the perforation was successful in 16 patients  (88.9%).  The perforation was closed by 1 stitch in 11 patients (61.1%), by 2 stitches in 4 patients (22.2%), and  by  3 stitches in  3 patients (16.7%).

The  operative time  ranged between 75 minutes and 110 minutes with a mean of 90 minutes. Most of this time was consumed for peritoneal lavage especially in patients with bowel adhesions and inter-loop collections.In the 2 patients  converted to laparotomy, the operative  time ranged between  100 minutes and 115 minutes.

Post-operatively, VAS pain score ranged between 3 and 6 with a mean of3.5 in the first post-operative day. It ranged between 2 and 4 in the second post-operative day with a mean of 2.4. The patients needed  post-operative parenteral narcotics for a period  ranging between 1 and 2 days with a mean of 1.5 days.

All the patients started on clear fluids on the 2nd post-operative day, and were allowed soft diet on the 3rd post-operative day, then full diet on the 4th post-operative day except the patients who were converted to laparotomy who were  kept  fasting for 3 days  post­ operatively. The duration of hospital stay ranged between 3 and 5 days with a mean of

4.5 days.

Regarding  post-operative complications, only 1 patient (5.6%) developed pelvic intra­ abdominal collection that  was  treated by

ultrasound guided drainage and LV. antibiotics. One patient (5.6%) developed umbilical port site wound infection that was treated by wound drainage under local anesthesia, daily dressing, and oral antibiotics. In these 2 patients  the procedure was completed laparoscopically. No chest infection,  leakage from the repair site, or mortality  were recorded  in the study. All patients tolerated oral intake without prolonged ileus.

All patients  were followed  up in the out­ patient clinic 2 weeks, 3 and 6 months post­ operatively with  no  significant long  term complications.

Discussion:

Laparoscopic surgery is replacing gradually the openone in the treatment of different gastro­ intestinal diseases as it is associated with less pain, shorter hospital stay, less scaring, and faster recovery.7 However, the implementation of laparoscopic approach in the management of perforated peptic ulcer is slowly evolving and  is  still  unavailable in  many  surgical departments. This may be explained by the fact that the decision to do laparoscopy depends on the laparoscopic experience of the surgeon on duty. Laparoscopic repair of the perforation is usually done by few enthusiastic surgeons capable of performing advanced laparoscopic procedures.8

So, we conducted this study trying to assess the efficacy oflaparoscopy in perforated peptic ulcer  repair. Peptic  ulcer  disease is  more prevalent in males than females, more in middle age group. Predisposing factors include NSAID use, Helicobacter pylori infection, smoking, high body mass index, and habitual  tea and coffee drinking.9-11 This  study included  18 patients with a mean age of35.6 years. 77.8% of them were males and 22.2% were females. These results are consistent with the results of Bertleff & Lange12 who reported in their study a mean age of 48 years and male predominance (79%). Also, Vaidya et al13 reported a mean age of38.5 years among their patients with a male to female ratio of27:4.

However, Bertleff et al14 reported a mean

age of 66 years  in their study  with a male: female ratio of 1.3:1 for patients submitted to laparoscopic repair of perforated peptic ulcer.

History of peptic ulcer disease was positive in 16.7% of our patients. These results are in accordance with  the  results  of many  other studies like Lee et ai15 and Ates et ai16 who reported a positive ulcer history in 23% and

14.3% of patients respectively.

In our  study,  50%  of the  patients were smokers  and 27.8%  of patients were  using NSAIDs more than 2 weeks  prior  to the perforation. Bertleff & Lange12 reported 62% incidence  of smoking  and 20% incidence  of NSAIDs use in their study. Also, Vaidya et al13 reported a smoking  rate of 61.3%  and NSAIDs use rate  of 32.3%  in their  study.

The perforation was diagnosed in our study by demonstration of free  air  under the diaphragm in the plain X-ray of the abdomen in the erect position  in 15 patients (83.3%), while in the other 3 patients (16.7%) the free air was demonstrated by the CT scan of the abdomen. Bertleff & Lange12 reported that the free air can be seen on the plain X-ray in 85% of the patients. Ates et al16 reported a higher incidence (94%) of demonstration  of free air in the plain abdominal X-ray.

However, even in the absence of the free air  in the  plain abdominal X-ray, the laparoscopy can be very useful  in cases of acute abdomen for diagnosis and localization of the site of perforation. Sauerland et al17 found in their study that in 7% of cases, there was a diagnosis different from perforated peptic ulcer  and  they  concluded the  benefit of laparoscopy as a diagnostic procedure indicating either an upper or lower laparotomy incision  or continuation of the laparoscopy.

It is important to preselect patients who are

good candidates for laparoscopic repair of the perforation.IS Boey's classification appears to be  useful for  patients'  selection.19 This classification depends on 3 risk factors:shock on  admission, American Society of Anesthesiologists (ASA)  grade  III-IV,  and more than 24 hours duration of symptoms. The minimum score is 0 and the maximum one is

3. Many  authors  reported  that laparoscopic repair is only safe for patients with Boey's score 0 and 1.20,21 Also, Thorsen et al22reported in their study that 86% of patients with perforated peptic ulcer treated laparoscopically were Boey's score 0 and 1. So, in our study,

we excluded patients who presented by septic shock, hemodynamic instability, patients with upper abdominal surgeries, and patients with duration of symptoms more than 24 hours.

During surgery, we put the patient in Llyod­ Davis' position with  the surgeon standing between patient' thighs. Many surgeons prefer to do laparoscopy in this position.l3,16 However, other surgeons prefer to stand on the patient's left hand,l9,23 The number of ports used for laparoscopic repair of perforated peptic ulcer differs from  one  study  to  another. Some surgeons prefer to use 4 ports: 10-mm umbilical port for the camera, two 5-mm working ports in right and left mid-clavicular lines, and a fourth 5-mm port just below xiphoid process for liver retraction.13,19,23 In our study, we succeeded to perform the  laparoscopic procedure in all the patients with only 3 ports without the use of the 4th port for liver retraction which is similar to the technique used by Lo et al.16 The ulcer was closed by 1 to 3 stitches over a pedicled omental flap by intra-corporeal knotting as the extra-corporeal suturing is likely to cut through the friable edge  of the perforation.24

Cellan-Jones was the first one who described the use of the pedicled omental  flap to plug the perforated ulcer in 1929.25 He advised this technique to prevent tearing out of the sutures and prevent  enlargement of the size  of the perforation by the damage of the friable edges. This technique is usually called "Graham's patch". However, Graham in his original article published in 193726 described  plugging  the site of the perforation by a free omental plug, a technique that is rarely  used by surgeons nowadays.

Ates et aJ16 tried to shorten the operative

time by simple closure of the perforated ulcer without using pedicled omentoplasty. However, avoiding omentoplasty might be the reason for a higher incidence ofleakage from the repaired

ulcer site.27

Another cause of increasing the operative time  of  the  laparoscopic technique is the meticulous peritoneal irrigation which is a very crucial step to prevent post-operative intra­ abdominal collections and sepsis. We did in our cases thorough peritoneal irrigation till we were sure that adequate control of the intra-

abdominal soiling  had been  achieved. The irrigation through the  5-mm  port  is  time consuming  and it takes up to 1 hour in some studies.28 Many authors13,29 demonstrated the great  effect of  laparoscopic irrigation in controlling the intra-abdominal contamination and  decreasing the  septic abdominal complications in cases of prolonged peritonitis. However, some surgeons claimed that there is no evidence that irrigation lower the risk of sepsis.30 So, irrigation may be necessary only if there  are food  particles in the abdomen.

On the other hand, some studies  showed that gas insufflation in the peritoneal  cavity with excessive  irrigation may be associated with  increasing bacterial translocation and septic complications in patients with prolonged peritonitis.27,31 They concluded that the use of laparoscopy in patients with  prolonged peritonitis might be associated with increasing risk of sepsis.24,27 Gupta  et aJ32 considered that increased use of irrigation fluid, possibly producing greater contamination of the peritoneal cavity, might have an impact on the intra-abdominal abscess formation after laparoscopic procedures like appendectomy. Memon33 reported  in his study  that carbon dioxide pneumoperitoneum may contribute to the mechanical diffusion of bacteria inside the peritoneal  cavity,  but experimental proof is lacking.

The reasons  for use of abdominal  drains post-laparotomy are  variable. They  may obliterate the deadspace, evacuate any collected blood and serum, drain residual contamination, detect any early leak, provide a track for late leaking, and reassure the surgeon when he is unhappy  about the anastomotic  technique.34

On the contrary, other surgeons  believe that the  drains  actually stimulate serous fluid formation; increase risk of infection; increase rate  of leakage by preventing omental mobilization, thereby obstructing its sealing action on the anastomotic suture line; and even create leakage by mechanical  erosion of the anastomosis.35,36 Drains also may increase the rate  of surgical wound  infection, increase patient discomfort, prolong hospital stay, and thereby increase the cost.37 The early detection of the anastomotic  leak by the drain remains speculative. Urbach et al38 in a meta-analysis

of 4 randomized controlled trials that included

414  adult  patients with  colonic or  rectal anastomosis, reported that of 20 observed leaks that occurred in patients with drains in place, in only  1 case  did  pus or enteric  contents appeared in the effluent of the existing drain.

In  our  study, we  did  not  insert intra­ abdominal drain in any of our patients because we thought that adequate  peritoneal  wash is enough and the presence of the drain does not prevent the development of intra-abdominal collections.Inspite of omitting drain insertion, we had only 1 patient  who developed  post­ operative  intra-abdominal collection (5.6%). These results are consistent with the results of Lo et al39 that did not use drains in their cases. None of these cases developed post-operative collection. Also, Lam et al40 mentioned in their study that the drain use is optional. They used the drain only in cases of severe contamination. They had only one patient with post-operative intra-abdominal collection out of35 patients with perforated peptic ulcer treated laparoscopically.

Nevertheless, many other studies adopted the routine use of the drain after laparoscopic repair  of  perforated peptic  ulcer.I3,16,19,23

Causes of conversion  in the literature are many. These causes included big perforation size,12 technical  difficulties, 13 and failure to locate the perforation.41 Shock on admission was associated with a higher conversion rate.31

Furthermore, time lapse between perforation and presentation negatively influenced the conversion rate.31 The conversion rate in our study was 11.1% as 2 patients required mid­ line laparotomy for proper control of the intra­ abdominal sepsis. This rate is in accordance with many other studies. Vaidya et al13 reported conversion in 2 out  of 31 patients (6.5%) although all of their patients presented  more than 24 hours after the onset  of pain. Siu et al42 reported a conversion rate of 14.2% among

63 patients. On the other hand, some studies reported 0% conversion  rate as Palanivela et al24 and Lee et al15 who treated 120 patients and 13 patients consecutively with laparoscopic repair of perforated peptic ulcer. In a review of 29 studies, Bertleff & Lange12 found that the overall conversion rate is 12.4% in a total of 2788 patients.

In the beginning of the study, the operative time was about 110 minutes and decreased gradually to be around 75 minutes towards the end of the study with a mean of 90 minutes. The operative  time is widely variable  in the literature. Linevicius & Morkevicius19 reported an operative time of76.2±35.3 minutes. Lam et al40 reported an operative time of 86 minutes. Lo et aJ39 reported an operative  time of 50 minutes for patients treated by ulcer closure with omental patch and 45 minutes for patients treated with simple ulcer closure only. Lee et ail5 reported  a shorter  operative  time; only

20.7±4.9 minutes.

Our study showed that the laparoscopic treatment of perforated peptic ulcer gives the patient  all the advantages of the minimally invasive surgical technique. The patients had less post-operative pain (a mean VAS score of 3.5  in the 1st  post-operative day),  less narcotics need (a mean of 1.5 days), earlier recovery of the post-operative ileus (all of them tolerated  soft diet by the 3rd post-operative day), and shorter hospital stay (a mean of 4.5 days). The different  studies in the literature confirmed the better post-operative course for the laparoscopic technique if compared to the

open one.8,14,27,42,43

Post-operatively, 1 patient (5.6%) developed pelvic intra-abdominal collection, and 1 patient (5.6%) developed umbilical port site wound infection. No post-operative leakage, prolonged ileus, chest infection, or mortality was reported in our study. Bertleff et al14 reported a mortality rate of 3.8%, ileus and wound infection  rate ofO%, and leakage rate of3.8%.

Elbroend  & Andersen8  reported in their

study that 67% of cases had smooth post­ operative course with no complications, 10% had intra-abdominal abscess, 11.7% had wound infection, 5.8%  had  pneumonia, and  the mortality rate was 4%.

In conclusion, laparoscopic repair of perforated peptic  ulcer  is safe and  reliable technique. It gives the patient all the advantages of laparoscopic surgery  with accepted  post­ operative morbidity and  mortality rates. However, laparoscopic closure of  the perforation is technically demanding. It should be considered as a good choice in the presence of  reasonable laparoscopic skills and experience.

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