Simple suture with or without proximal gastric vagotomy for perforated duodenal ulcer

A Prospective Clinicoendoscopic Follow-up Study in Young Patients with Peptic Ulcer Perforation at a Tertiary Institute in Central India

BACKGROUND

Perforation peritonitis is one of the commonest encountered emergencies in the surgery casualty. This study was conducted with the aim of identifying risk factors in peptic ulcer disease (PUD) in young patients.

MATERIALS AND METHODS

Seventy patients were evaluated in this study and were followed up with clinical examination and endoscopy at 8 weeks and 6 months.

RESULTS

Out of the total 70 patients, there was a mortality of 5 patients and 7 patients were lost to follow-up. Out of the remaining 57 patients, 56 were men and 1 was a woman. Maximum patients were from the age group of 35-40 years. The patients were categorized on the basis of their clinical symptoms and endoscopy results at the follow-up of 6 months in 4 categories-21 patients having an active ulcer and symptomatic, 15 patients having active ulcer but no symptoms, 16 patients who were asymptomatic and without an active ulcer and 5 patients nonulcer dyspepsia.

CONCLUSION

Postoperative treatment with H2 blockers or proton pump inhibiters along with anti-Helicobacter pylori regimen should be prescribed for all patients with peptic ulcer perforation. Routine endoscopic examination of such patients should also form a part of the follow-up to look for ulcer healing postoperatively.

HOW TO CITE THIS ARTICLE

Jahagirdaar D, Bomanwar N, Joshi S. A Prospective Clinicoendoscopic Follow-up Study in Young Patients with Peptic Ulcer Perforation at a Tertiary Institute in Central India. Euroasian J Hepato-Gastroenterol 2019;9(2):91-95.

Acute Vagotomy Does Not Augment the Systemic Inflammatory Response in Patients with Peptic Ulcer Disease

Recent accumulating evidence suggests that the vagus nerve modulates the response to peripheral immunologic stimuli and that intact vagal mediation decreases the systemic inflammatory response. We hypothesized that patients who had vagotomy for complicated peptic ulcer disease would be at increased risk of an enhanced systemic inflammatory response compared to patients that did not have a vagotomy as part of their operative treatment. Ninety-six patients were identified from 1985 to 2000 and their medical records were reviewed. Patients were assigned to three groups based on the performance of a truncal vagotomy: truncal vagotomy (TV; N = 62 patients), nontruncal vagotomy (NTV; N = 34 patients), or a subgroup of the TV group, acute truncal vagotomy (ATV; N = 40 patients). Operative indications in the NTV and ATV groups were perforation (94% vs 47%) and bleeding (6% vs 53%). Systemic or organ-specific complications did not differ between groups (NTV vs ATV), and the sepsis (24% vs 23%) and mortality rates (29% vs 20%) were similar. The ICU and hospital length of stay did not differ substantially among the groups. This clinical study demonstrated that acute truncal vagotomy does not increase the risk of the systemic inflammatory response in surgical patients with complicated peptic ulcer disease.

[Surgical treatment of perforated gastric ulcer]

INTRODUCTION

Peptic ulcer perforation is a complication of ulcer disease which requires urgent surgical treatment. The aim of this paper was to point out our experience in surgical treatment of perforated peptic ulcer.

MATERIAL AND METHODS

This retrospective study analyzes results of surgical treatment in 365 patients with perforated peptic ulcer during the period January 1996 to December 2000.

RESULTS

During the last 5-year period 365 patients were treated following peptic ulcer perforation. The average age was 43.53 +/- 8.26, with the span from 18 to 86. The most frequent surgical procedures in treatment of peptic ulcer perforation were: simple closure with biopsy (55.88%), excision of the ulcer with a pyloroplasty and vagotomy (35.29%) as nonresection surgical procedures and stomach resection after Billroth II (8.83%). The postoperative mortality was 4.41%.

CONCLUSIONS

The methods of choice in surgical treatment of gastric ulcer perforation are nonresection surgical procedures with drug therapy and eradication of Helicobacter pylori, if present.

Eradication of Helicobacter pylori prevents recurrence of ulcer after simple closure of duodenal ulcer perforation: randomized controlled trial

OBJECTIVE

In this randomized trial, the authors sought to determine whether eradication of Helicobacter pylori could reduce the risk of ulcer recurrence after simple closure of perforated duodenal ulcer.

BACKGROUND DATA

Immediate acid-reduction surgery has been strongly advocated for perforated duodenal ulcers because of the high incidence of ulcer relapse after simple patch repair. Although H. pylori eradication is now the standard treatment of uncomplicated and bleeding peptic ulcers, its role in perforation remains controversial. Recently a high prevalence of H. pylori infection has been reported in patients with perforations of duodenal ulcer. It is unclear whether eradication of the bacterium confers prolonged ulcer remission after simple repair and hence obviates the need for an immediate definitive operation.

METHODS

Of 129 patients with perforated duodenal ulcers, 104 (81%) were shown to be infected by H. pylori. Ninety-nine H. pylori-positive patients were randomized to receive either a course of quadruple anti-helicobacter therapy or a 4-week course of omeprazole alone. Follow-up endoscopy was performed 8 weeks, 16 weeks (if the ulcer did not heal at 8 weeks), and 1 year after hospital discharge for surveillance of ulcer healing and determination of H. pylori status. The endpoints were initial ulcer healing and ulcer relapse rate after 1 year.

RESULTS

Fifty-one patients were assigned to the anti-Helicobacter therapy and 48 to omeprazole alone. Nine patients did not undergo the first follow-up endoscopy. Of the 90 patients who did undergo follow-up endoscopy, 43 of the 44 patients in the anti-Helicobacter group and 8 of the 46 in the omeprazole alone group had H. pylori eradicated; initial ulcer healing rates were similar in the two groups (82% vs. 87%). After 1 year, ulcer relapse was significantly less common in patients treated with anti-Helicobacter therapy than in those who received omeprazole alone (4.8% vs. 38.1%).

CONCLUSIONS

Eradication of H. pylori prevents ulcer recurrence in patients with H. pylori-associated perforated duodenal ulcers. Immediate acid-reduction surgery in the presence of generalized peritonitis is unnecessary.

Helicobacter pylori status and endoscopy follow-up of patients having a history of perforated duodenal ulcer

BACKGROUND

The aim of this study was to determine whether the recurrence of symptoms or ulcer disease in patients with a history of perforated duodenal ulcer is related to Helicobacter pylori infection.

METHODS

One hundred sixty-three consecutive patients with history of perforated duodenal ulcer unrelated to nonsteroidal anti-inflammatory drugs underwent upper endoscopy. Any recurrent symptoms or complications were documented. Regardless of the endoscopic findings, three antral biopsy specimens were taken for histologic examination and a rapid urease test.

RESULTS

There was a preponderance of men (male/female = 5.3:1). The mean age was 55.9 years. Sixty-seven (41.1%) patients gave a history of recurrent epigastric pain, seven of whom also had a history of bleeding ulcer. Upper endoscopy was performed at a mean of 74.5 +/- 7.1 months after operation. Positive endoscopic findings were noted in 68 (41.7%) patients; H. pylori was found in the biopsy specimens from 77 (47.2%) patients. Recurrent duodenal ulcer was found in 29 (17.8%) patients and was significantly related to male gender, recurrent epigastric pain, bleeding ulcer, longer interval from previous operation, and positive H. pylori status. Positive H. pylori status and male gender were independent factors associated with recurrent duodenal ulcer.

CONCLUSIONS

Recurrent ulcer disease in patients with a history of perforated duodenal ulcer is related to H. pylori infection.

Perforated pyloroduodenal ulcers. Long-term results with omental patch closure and parietal cell vagotomy

OBJECTIVE

The authors evaluated parietal cell vagotomy and omental patch closure as treatment for perforated pyloroduodenal ulcers.

BACKGROUND DATA

Since the beginning of the century, there has been a difference of opinion as to whether perforated pyloroduodenal ulcers are best managed with nonoperative treatment, simple closure, or definitive treatment, i.e., a procedure that handles the emergency problem and simultaneously provides protection against further ulcer disease. The criticism of using definitive treatment at the time of perforation has been that some patients who might not have recurrent ulcer, if a definitive operation was not performed, would be at risk of adverse postoperative sequelae, including death. Parietal cell vagotomy as treatment of intractable duodenal ulcer disease was shown to be almost without complications. The objective of this study was to determine if the operation was equally applicable to perforated pyloroduodenal ulcers.

METHODS

A group of 107 selected patients with perforated pyloroduodenal ulcers underwent definitive treatment by omental patch closure and parietal cell vagotomy. The patients were evaluated prospectively on an annual basis up to 21 years. Gastric analyses were performed on each visit for which the patient gave his/her consent. Patients suspected of a recurrent ulcer were examined endoscopically for verification.

RESULTS

There was one death (0.9%). Ninety-three patients were observed for follow-up for 2 to 21 years. The recurrent ulcer rate by life table analysis was 7.4%. The reoperative rate was 1.9%. Postoperative gastric sequelae were insignificant. All but four patients were graded Visick I or II at the time of their last evaluation.

CONCLUSION

This study confirms that the combination of parietal cell vagotomy and omental patch closure is an excellent choice for treatment of patients with perforated pyloroduodenal ulcers, who, by virtue of their age, fitness, and status of the peritoneal cavity are candidates for definitive surgery. Virtually none of the morbidity that occurs with other forms of definitive treatment is inflicted on patients who might never have needed a definitive operation if simple closure was performed. At the same time, it provides definitive therapy for the larger number of patients who subsequently would have required a second operation for continued ulcer disease if simple closure alone was performed. Whether this operation is performed at the time of perforation should depend on the presence or absence of risk factors, rather than whether the ulcer is acute or chronic.

Alternative laparoscopic management of perforated peptic ulcers

Surgery--namely, suture closure-is still the treatment of choice for perforated peptic ulcers, despite the proven efficacy of Taylor's conservative approach. Such conservative management, however, has been proven less effective in high-risk patients and those with perforations more than 12 h old. Here we suggest alternative laparoscopic treatments for perforated peptic ulcers. We have treated laparoscopically six patients (one F, five M; mean age 57.6 years; range 31-81 years); the mean duration of the operation was 52 min; the median hospital stay was 7 days (6-15 days); H2-blockers, antibiotics, and fluids were administered in the p.o. course; the follow-ups range from 6 to 18 months. On the basis of our experience, the treatment of choice for perforated peptic ulcers is Taylor's conservative procedure and laparoscopic drainage of the abdominal cavity when there is mild peritoneal reaction (usually less than 6 h from the onset of perforation). In case of remarkable peritonitis (usually more than 12 h), it is mandatory to add an accurate lavage. When the site of perforation is concealed by the peritoneal inflammation it should not be searched; when visible, it might be obliterated with the round ligament or an omental tissue strand, particularly if larger than 1 cm in diameter.

Laparoscopic repair of ruptured duodenal peptic ulcer: a case report

Ruptured duodenal peptic ulcer is a serious complication of ulcer disease that occurs in approximately 5% of cases and accounts for over 70% of deaths associated with peptic ulcer disease. This case report details the management of a 67-year-old male with a ruptured duodenal peptic ulcer who presented to the emergency room with acute onset of severe abdominal pain. There was no past history of ulcer disease. An abdominal x-ray suggested the presence of free air, and diagnostic laparoscopy was performed. The superior exposure afforded by this minimally invasive technique not only permitted an exact diagnosis to be made, but also afforded a means to expeditiously correct the pathologic defect.

Generalized peritonitis in India--the tropical spectrum

Generalized peritonitis is a common surgical emergency in India, the 'Tropical Spectrum' of generalized peritonitis being different from the western spectrum. A total 155 cases of generalized peritonitis were surgically treated at the All India Institute of Medical Sciences between 1981 and 1987, all patients undergoing peritoneal toilet with drainage after the cause of their peritonitis had been treated. The most common cause of peritonitis was peptic ulcer perforation, with simple closure being associated with a 2 per cent mortality, while typhoid perforation was the second most common cause. The diagnosis was clinical, supported by the operative findings of a terminal ileal perforation while bacteriological, serological and histopathological confirmation was retrospective. Appendicular perforations were less common than in the west but the clinical picture was the same. Tubercular perforations were not uncommon with a previous history of subacute intestinal obstruction and evidence of tuberculosis on chest X-ray suggesting the diagnosis. Ruptured amebic liver abscess was the most common hepatobiliary cause of generalized peritonitis with drainage of the abscess producing good results. The average hospital stay was 15 days with an overall mortality of 8 per cent.

Simple closure of perforated duodenal ulcer: a prospective evaluation of a conservative management policy

One hundred and thirteen consecutive patients admitted with a perforated duodenal ulcer over a 5-year period (1978-82) and treated by simple closure have been followed prospectively over a median period of 43 months. Patients were divided into two categories according to their previous history of dyspepsia; group 1 (66 patients) with a chronic history of more than 3 months and group 2 (47 patients) where there was no history of dyspepsia or a history of less than 3 months duration. The follow-up periods were similar (group 1, 44 months; group 2, 43 months). The overall recurrence rate was 42 per cent and to date only 14 per cent of the total group of 113 patients have required a definitive operation. The incidence of ulcer recurrence was higher in group 1 than in group 2 in terms of total recurrence (group 1, 50 per cent; group 2, 32 per cent) and patients requiring further surgery (group 1, n = 14, 21 per cent; group 2, n = 7, 15 per cent). Five of these 21 patients required an emergency procedure for haemorrhage or reperforation (group 1, n = 2; group 2, n = 3). There were no significant differences between the 5-year predictive recurrence rate or the requirement for definitive surgery between the groups. Five of the 27 patients currently on medical treatment have required maintenance treatment while the remaining patients receive active treatment for a mean of 20 per cent of the time since they developed recurrent ulceration. These results support continuation of our 'wait and see' policy following simple closure of perforated duodenal ulcer, even in patients with a history of chronic dyspepsia.

Indications for parietal cell vagotomy without drainage in gastrointestinal surgery

Parietal cell vagotomy (PCV) was used for a variety of gastrointestinal conditions in 658 patients. Operative and late related deaths after PCV were 1.1% (3/273) in patients with intractable duodenal ulcers, 1.1% (1/91) in perforated ulcers, 0% (0/43) in Type I gastric ulcers, 0% (0/45) in pyloric and prepyloric ulcers, 3.2% (6/188) when combined with fundoplication, 8.7% (2/23) when combined with vascular surgery, and 4.2% (1/24) in ulcer patients with acute bleeding. The recurrent ulcer rate after PCV was 8.4% in patients operated on for duodenal ulcer, 6.4% for perforated ulcer, 5.3% for bleeding ulcers, 10% for Type I gastric ulcers, and 31% for pyloric and prepyloric ulcers. PCV was preferred to total gastrectomy in four patients in whom a gastrinoma could not be located. PCV was used in 188 patients with reflux esophagitis and in 12 patients with achalasia to facilitate fundoplication and placement of the myotomy, respectively. Based on the results of the study, PCV is contraindicated in patients with pyloric and prepyloric ulcers. PCV is not recommended when traumatic dilatation of the pylorus is required to overcome obstruction. PCV may have limited application in patients with bleeding ulcers and Type I gastric ulcers. In our experience PCV is not contraindicated in patients with ulcers resistant to H2 receptor antagonists. PCV may be contraindicated when acid hypersecretion exceeds an as-yet undetermined level. PCV is an ideal procedure for intractable duodenal ulcers and perforated ulcers.

A randomized trial of nonoperative treatment for perforated peptic ulcer

To determine whether surgery could be avoided in some patients with perforated peptic ulcer, we conducted a prospective randomized trial comparing the outcome of nonoperative treatment with that of emergency surgery in patients with a clinical diagnosis of perforated peptic ulcer. Of the 83 patients entered in the study over a 13-month period, 40 were randomly assigned to conservative treatment, which consisted of resuscitation with intravenous fluids, institution of nasogastric suction, and intravenous administration of antibiotics (cefuroxime, ampicillin, and metronidazole) and ranitidine. Eleven of these patients (28 percent) had no clinical improvement after 12 hours and required an operation. Two of the 11 had a perforated gastric carcinoma, and 1 had a perforated sigmoid carcinoma. The other 43 patients were assigned to immediate laparotomy and repair of the perforation. One of these patients was found to have a perforated gastric carcinoma. The overall mortality rates in the two groups were similar (two deaths in each, 5 percent), and did not differ significantly in the morbidity (infection, cardiac failure, or renal failure) rates (40 percent in the surgical group and 50 percent in the nonsurgical group). The hospital stay was 35 percent longer in the group treated conservatively. Patients over 70 years old were less likely to respond to conservative treatment than younger patients (P less than 0.05). We conclude that in patients with perforated peptic ulcer, an initial period of nonoperative treatment with careful observation may be safely allowed except in patients over 70 years old, and that the use of such an observation period can obviate the need for emergency surgery in more than 70 percent of patients.

Current status of proximal gastric vagotomy

Proximal gastric vagotomy is nearing its twentieth year in clinical use as an operation for peptic ulcer disease. No other acid-reducing operation has undergone as much scrutiny or study. At this time, the evidence of such studies and long-term follow-up strongly supports the use of proximal gastric vagotomy as the treatment of choice for chronic duodenal ulcer in patients who have failed medical therapy. Its application in treating the complications of peptic ulcer disease, which recently have come to represent an increasingly greater percentage of all operations done for peptic ulcer disease, is well-tested. However, initial series suggest that it should probably occupy a prominent role in treating some of these complications, particularly in selected patients, in the future. The operation has the well-documented ability to reduce gastric acid production, not inhibit gastric bicarbonate production, and also minimally inhibit gastric motility. The combination of these physiologic results after proximal gastric vagotomy, along with preservation of the normal antropyloroduodenal mechanism of gastrointestinal control, serve to allow patients with proximal gastric vagotomy the improved benefits of significantly fewer severe gastrointestinal side effects than are seen after other operations for peptic ulcer disease.

Proximal gastric vagotomy. The preferred operation for perforations in acute duodenal ulcer

Simple closure, the conventional operation for perforated acute duodenal ulcers, is associated with symptomatic relapse in a large proportion of patients. In order to assess the role of immediate definitive surgery, 78 fit patients with perforated acute ulcers were prospectively randomized to undergo either closure alone or proximal gastric vagotomy with closure (PGV). Patients taking potentially ulcerogenic drugs or who had severe stress were excluded from the study. Both groups were comparable with respect to age, sex, general medical health, duration of perforation, length of ulcer history, and presence of duodenal scarring. There was no hospital mortality. Minor complications occurred in 7.3% after closure and 10.8% after PGV. At 3 years follow-up, the cumulative recurrence rates were 36.6% and 10.6% after closure and PGV, respectively (p = 0.001). Eighty-five per cent of recurrences after closure were symptomatic, and half of them required reoperation. Duodenal scarring itself did not appear to influence the outcome after closure. PGV was not associated with dumping, diarrhea or other unwanted side effects. Although less than that in chronic ulcers, there is a substantial risk of symptomatic relapse after closure of perforated acute duodenal ulcers. With judicious patient selection, PGV effectively reduces this risk without incurring disabling side effects associated with other ulcer operations.

Perforated peptic ulcer

Peptic ulcer disease has declined significantly since 1950 in industrialized nations. However, the number of patients with perforated and bleeding ulcers has been constant or has declined only slightly, except for older patients, in whom the frequency has increased. In patients with perforated ulcers, operative management is preferable to non-operative treatment. The operative choices are simple closure of the perforation or definitive surgery. Patients who have significant risk factors should undergo simple closure. Closure of the ulcer with parietal cell vagotomy is the author's first choice for definitive operative treatment when this procedure can be performed.

[Initial interventions in ulcer disease: indications--choice of procedure--results]

Routine use of H2 receptor blockers in the therapy of chronic gastroduodenal ulcers reduced the number of ulcer operations. The ulcer recurrence rate in postpyloric and duodenal ulcer seems to be lower after highly selective vagotomies than during long term maintenance treatment, prepyloric ulcers are treated best by gastric vagotomy and antrectomy. In the absence of risk factors perforated gastroduodenal ulcers are treated better by definitive surgery (suture plus vagotomy) than by simple suture.