Perforated Peptic Ulcers

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downstatesurgery.orgPerforated peptic ulcersDr V. RoudnitskyKCH

downstatesurgery.orgPeptic ulcer disease Peptic ulcers are focal defects in the gastric orduodenal mucosa that extend into thesubmucosa or deeper Caused by an imbalance between mucosaldefenses and acid/peptic injury The costs of PUD, including lost work time andproductivity, are estimated to be above 8 billionper year in the United States In the United States with a prevalence of about2%, and a lifetime cumulative prevalence ofabout 10%, peaking around age 70 years

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downstatesurgery.orgHelicobacter Pylori 50% of the world's population is infected with H. pylori Only 10 to 15% of patients colonized with H. pylori willdevelop 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 themost potent antagonist to antral gastrin secretion) The end result is hypergastrinemia and acid hypersecretion

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downstatesurgery.orgOther causative agents :1. Drugs (all NSAIDs, aspirin,and cocaine)2.Smoking3.Alcohol4.Psychologic stress.In the United States, probablymore than 90% of seriouspeptic ulcer complicationscan be attributed to H. pyloriinfection, NSAID use, and/orcigarette smoking.

downstatesurgery.orgModified Johnson classification for gastric ulcer

downstatesurgery.orgThe incidence of emergency surgeryand the death rate associated withpeptic ulcers has not changedsignificantly for last few decades

downstatesurgery.orgSURGICAL COMPLICATIONS OF PEPTICULCER DISEASE Perforation Bleeding Gastric Outlet Obstruction Intractable disease

downstatesurgery.orgSURGICAL COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION Acute perforations of the duodenum are estimatedto occur in 2% to 10% of patients with ulcers Surgery almost always indicated Conservative management should considered inpatients who do not have :– generalized peritonitis– hemodynamic instability– free peritoneal perforation on a Gastrografin uppergastrointestinal study

downstatesurgery.orgSURGICAL COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION Conservative management––––serial physical and laboratory examinationsnasogastric suctionintravenous acid secretion suppressionintravenous broad-spectrum antibiotics In any time during conservative management thepatient deteriorates, an operation is indicated Retrospective and prospective, randomizedstudies suggest that conservative management iseffective in properly selected patients

downstatesurgery.orgCrofts TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperative treatmentfor perforated peptic ulcer. New Eng J Med 1989;320:970–973Berne TV, Donovan AJ. Nonoperative treatment of perforated duodenal ulcer. ArchSurg 1989;124:830–832Keane TE, Dillon B, Afdhal HH, et al. Conservative management of peforatedduodenal ulcer. Br J Surg 1988;75:583–584Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer: An alternativetherapeutic plan. Arch Surg 1998;133:1166–1171Marshall C, Ramaswamy P, Bergin FG, et al. Evaluation of a protocol for thenonoperative management of perforated peptic ulcer. Br J Surg 1999;86:131–134

downstatesurgery.orgSURGICAL COMPLICATIONS OF PEPTICULCER DISEASE : PERFORATION Appropriate surgical management of perforatedulcers remained controversial :– Simple patch ( laparoscopic or open) vs antiulceroperation?

downstatesurgery.orgCellan-Jones(1929) /GrahamPatch(1937)

downstatesurgery.orgComparison Between Open and Laparoscopic Repairof Perforated Peptic Ulcer DiseaseWorld J Surg (2008) 32:2371–2374 Prospective , non randomized studyAugust 2006-2007, 33 patient included, single institutionLaparoscopic patch 19, open Patch 14The primary end points :–––––––––total operative timenasogastric tube utilisationintravenous fluid requirementtotal time of urinary catheter and abdominal drainage usagereturn to normal dietintravenous/intramuscular opiatetime to full mobilizationtotal in-patient hospitalstay.

downstatesurgery.orgComparison Between Open and Laparoscopic Repairof Perforated Peptic Ulcer DiseaseWorld J Surg (2008) 32:2371–2374

downstatesurgery.orgTruncal Vagotomy The 2-cm length ofANTERIOR AND POSTERIORnerve is resected Esophagus should be morewidely mobilized for adistance of 4–5 cm above thegastroesophageal junction The "criminal nerve" ofGrassi – origin from posteriorvagus Frozen section should berequested to confirmvagotomy

downstatesurgery.orgSelective VagotomyPreserve: posteriorly derived vagalbranch that innervates thesmall intestine and pancreas anteriorly derived vagalbranch that supplies thegallbladder and liver involves interruption of bothnerves of Latarget andtherefore does not avoid theneed for a drainage procedure

downstatesurgery.orgHighly Selective VagotomyPreserve: posteriorly derived vagalbranch that innervates thesmall intestine and pancreas anteriorly derived vagalbranch that supplies thegallbladder and liver both nerves of Latarget andtherefore avoid the need fora drainage procedure

downstatesurgery.orgDrainage procedures( with TV or SV )Heinecke-Mikuliczpyloroplasty Full-thickness incisionextends from 2 cm proximalto 1–2 cm distal to the pyloricring The incision is closedvertically Illustration of Gambee stitch

downstatesurgery.orgDrainage proceduresFinney U-shaped pyloroplasty The inverted U-shapedincision into the lumens ofthe stomach and duodenum Suture of the posteriorseptum of the stomach andduodenum The first anterior tier ofsutures (Connell) is placed

downstatesurgery.orgBillrot 1 gastrectomyA.B.C.D.E.Reconstruction:Bilroth IHorsleyVon Haberer-FinneyVon HaberShoemaker

downstatesurgery.orgBilroth 2 gastrectomy

downstatesurgery.orgControlled tube duodenostomy in the management of giant duodenal ulcer perforation—a newtechnique 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

downstatesurgery.orgProcedure for type 4 gastric ulcer Pauchet procedure forulcer 2 cm from GEjunction Csendes procedure forulcer 2 cm from GEjunction.

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downstatesurgery.orgPre-operative risk scores for the prediction of outcome in elderlypeople who require emergency surgeryWorld Journal of Emergency Surgery 2007, 2:16

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downstatesurgery.orgNg 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 DU104(81%) with positive HPSurgery – simple patchRandomization:– HP therapy PPI– PPI therapy alone 1 Year endoscopic evaluation for recurrent ulcer:– HP therapy group – 5% of recurrent ulcer– PPI group – 38%

downstatesurgery.orgTrends and Outcomes of Hospitalizations for Peptic Ulcer Diseasein the United States, 1993 to 2006Ann Surg 2010;251: 51–58

downstatesurgery.orgTrends and Outcomes of Hospitalizations for Peptic Ulcer Diseasein the United States, 1993 to 2006Ann Surg 2010;251: 51–58

downstatesurgery.orgTrends and Outcomes of Hospitalizations for Peptic Ulcer Diseasein the United States, 1993 to 2006Ann Surg 2010;251: 51–58

downstatesurgery.orgEmerging Trends in Peptic Ulcer Disease andDamage Control Surgery in the H. pylori EraFrom the Department of Surgery, Harbor-UCLA Medical Center, Torrance, CaliforniaTHE AMERICAN SURGEON September 2005

downstatesurgery.orgThe management of large perforations of duodenal ulcersSanjay Gupta, Robin Kaushik*, Rajeev Sharma and Ashok AttriBMC Surgery 2005, 5:15

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downstatesurgery.orgWho is the Patient with PUD perforationwho 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?

downstatesurgery.orgDid HP treatment PPI have beenreplaced antiulcer surgery?

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, AfdhalHH, et al. Conservative management of peforated duodenal ulcer. Br J Surg. 1988;75:583–584 Donovan AJ, Berne TV, Donovan JA. Perforated duodenal ulcer .

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