Falciform ligament use in perforated duodenal ulcer repair: a case report and literature review

Safety and Efficacy of the Falciformopexy Technique for Peptic Ulcer Perforation: A Systematic Review and Meta-Analysis

ObjectivesPeptic ulcer perforation (PUP) is a severe complication of peptic ulcer disease, associated with significant morbidity and mortality. The Graham patch repair (GPR) is the standard surgical treatment; however, when the greater omentum is insufficient, falciformopexy has emerged as a viable alternative. This study aims to assess the efficacy and safety of falciformopexy for PUP through a systematic review and meta-analysis.MethodsA systematic search was conducted in PubMed, Scopus, Cochrane, Web of Science, and Ovid to identify studies reporting on PUP patients treated with falciformopexy. Outcomes evaluated included length of hospital stay, perioperative mortality, wound infections, and reoperation rates. A comparative analysis with patients treated with GPR was also performed. Safety and efficacy outcomes were analyzed using single proportions, while risk ratios (RR) with 95% confidence intervals were pooled for comparative assessments.ResultsSix studies involving 868 patients were included, of whom 148 underwent falciformopexy for PUP. The mean hospital stay was 8.76 days (95% CI: 6.5-11.02; I2 = 92%). The perioperative mortality rate was 4.38% (95% CI: 0%-10.26%; I2 = 53%), the wound infection rate was 6.66% (95% CI: 2.31%-11.02%; I2 = 0%), and reoperation was required in 1.76% of cases (95% CI: 0%-4.73%; I2 = 0%). Comparative analysis revealed no significant differences between the falciformopexy and GPR groups regarding mortality, wound infections, or reoperation rates.ConclusionThese results indicate that the use of the falciform ligament for PUP repair is associated with low perioperative mortality, wound infection, and reoperation rates, suggesting it is a viable alternative when the omentum is unavailable.

Advances and results in omental patch repair of gastrointestinal perforations: A narrative review

Omental patch repair is a crucial surgical procedure for managing gastrointestinal perforations, particularly those associated with peptic ulcers, necessitating a detailed review of its effectiveness and outcomes. This literature review aims to assess current knowledge on omental patch repair, focusing on advancements in surgical techniques and patient outcomes. Major medical databases, including PubMed, Scopus, and Web of Science, were searched for relevant studies published between 2020 and 2024, prioritizing those that explored omental patch repair, surgical methods, and associated clinical outcomes. The results provide insights into the pathophysiology of gastrointestinal perforations, the effectiveness of omental patch repair in promoting healing, and its role in reducing postoperative complications. Both open and laparoscopic techniques have demonstrated improved patient outcomes, including reduced mortality, morbidity, and faster recovery times. Additionally, alternative methods, such as the use of the falciform ligament, offer comparable efficacy in cases where the omentum is unavailable. This review underscores the importance of omental patch repair as a reliable surgical intervention adaptable to various clinical environments. However, further research is necessary to address gaps in long-term outcomes, particularly regarding recurrence rates and complications, highlighting the need for continued innovation and refinement of techniques to enhance patient care.

Laparoscopic Repair of Duodenal Perforation Using the Falciform Ligament: A Cross-Sectional Study

Background Duodenal perforation is a life-threatening condition. Laparoscopic repair using the falciform ligament is a minimally invasive technique that has shown promising results. We present a case series of patients who underwent laparoscopic repair of duodenal perforation using the falciform ligament as an alternative to conventional techniques. Methodology The present study was a cross-sectional study carried out in the Department of General Surgery, Sree Balaji Medical College and Hospital, Chennai, India, between January 2023 and August 2024. The study was carried out among all the patients who underwent laparoscopic repair of duodenal perforation using the falciform ligament. The data collection was done by the principal investigator, himself, using a semi-structured proforma. Results The mean operative time among the participants was 86.25 ± 17.07 minutes. The mean time to start liquids was 21.42 ± 3.26 hours, and the mean time to start solids was 37.67 ± 2.06 hours. No post-operative complications were reported or identified. The post-operative pain score was 2.55 ± 1.31. The mean post-operative satisfaction score was 8.59 ± 2.84. The mean duration of hospital stay was 5.51 ± 1.21 days. No participants had any complications or died during the follow-up period. The technical success rate was 100%. Conclusion Laparoscopic repair of duodenal perforation using the falciform ligament is a feasible and effective technique. This approach offers minimal invasiveness, reduced morbidity, and faster recovery. Our case series demonstrates the efficacy of this technique in managing duodenal perforation.

Pedicled falciform ligament flap use as an alternative surgical technique in peptic ulcer perforation repair: a case report and review of literature

Peptic ulcer disease (PUD) affects ~4 million people globally. Peptic ulcer perforation (PUP) is a serious complication of PUD associated with high mortality and morbidity. Hence, a high index of clinical suspicion is crucial in diagnosing such cases. Here, we present a case of a 19-year-old male who presented with 4 days of severe abdominal pain, fever, and vomiting. On examination, signs of acute abdomen were evident, and an erect chest X-ray confirmed free air under the diaphragm. The patient underwent an emergency midline laparotomy, during which 1000 ml of purulent fluid was evacuated. A perforation measuring 8 × 8 mm2 was repaired using the falciform ligament due to the unavailability of adequate healthy omentum. His postoperative recovery was uneventful. This case report underscores the importance of considering the falciform ligament as a viable and effective alternative for the closure of PUP when the omentum is unavailable.

Retrospective comparison of outcomes of patients undergoing omental patch versus falciform patch repair of perforated peptic ulcers

BACKGROUND

The omental patch repair is the gold standard for the repair of perforated peptic ulcers. This can be performed open or laparoscopically. However, in the event of non-viable or inadequate omentum available at the time of surgery the falciform ligament has been reportedly used to as an alternative. Nonetheless, evidence for its safety is scant. This study aims to determine differences in patient outcomes when comparing the two repair techniques.

METHODS

Following ethics approval, patients who underwent surgical repair of perforated peptic ulcers using omental or falciform patch repair, between 1 January 2010 and 31 December 2017, across all three Western Australian tertiary hospital services and at least 18 years of age were included. Data were collected by reviewing medical records of included patients.

RESULTS

Three hundred twenty-nine patients who underwent either open or laparoscopic repairs were included. Thirty-seven patients had falciform repairs and were mostly ASA of 2 compared to 292 patients receiving omental patch repair who were mostly ASA 3. Falciform patch repairs were more commonly used in duodenal ulcer perforations. There were no statistically significant differences in patient outcomes between the omental patch and falciform ligament groups. This included post-operative intra-abdominal sepsis, return to theatre, post-operative ICU admission, inpatient mortality, 30-day readmission and ulcer healing on follow-up gastroscopy.

CONCLUSIONS

This study demonstrates safety, efficacy and similar outcomes for patients receiving the falciform ligament patch repair compared with omental patch repair.

How to do laparoscopic repair of perforated anterior duodenal ulcers: a 'three arches' falciform patch technique simplifies the approach

Laparoscopic repair of perforated duodenal ulcers has proven superior results to open procedures though uptake has been poor. We describe the 'three arches' technique as a means of reducing technical difficulty and improving operative efficiency. Our case series of patients undergoing this technique for perforated peptic ulcer disease demonstrates comparable results to other methods of repair.

Spectrum of perforated peptic ulcer disease in a tertiary care hospital in South India: predictors of morbidity and mortality

BACKGROUND

Perforated peptic ulcer remains one of the most common surgical emergencies in India with significant morbidity and mortality. The aim of this study was to identify the perioperative risk factors influencing the post-operative morbidity and mortality in patients with perforated peptic ulcer disease.

METHODS

Five-hundred patients who underwent surgery for perforated peptic ulcer in our institution in the preceding 8 years were included in this observational retrospective study. Their clinical presentations, peri-operative managements were studied and analysed.

RESULTS

Five hundred cases were analysed of which 96% were males. Mean age was 46.5 years. A total of 160 patients had duodenal perforation and 328 had gastric perforation with a mean size of 8.6 mm. Most patients (96.2%) underwent omental patch closure of the perforation with mean length of hospitalization being 14 days. The most common major and minor postoperative complications were prolonged intubation and pulmonary complaints respectively. Re-exploration was needed in 6.2% of cases with a post-operative leak rate of 5.8%. Age >60 years, presence of comorbid illnesses, shock at presentation and perforation size >1 cm were identified as independent predictors of postoperative morbidity. Overall mortality was 11.6% while specific mortality among males and females were 11.8% and 5% respectively. Age >60 years, shock at presentation, presence of abdominal rigidity and size of perforation >1 cm were independent predictors of mortality.

CONCLUSION

Old age, comorbidities, shock at presentation, perforation size >1 cm, higher ASA grade, prolonged surgery and biliopurulent contamination >500 mL were independent predictors of both increased post-operative morbidity and mortality.

Utility of Falciform Ligament in Abdominal Surgery: A Systematic Review

OBJECTIVE

The aim of the present systematic review was to assess current trends in use of falciform ligament in abdominal surgery.

BACKGROUND

The falciform ligament has been proposed in surgical literature as a suitable pedicle or flap with acceptable surgical outcomes; however, it is underutilized in abdominal surgery.

METHODS

We performed a literature search and meta-analysis. All English studies describing use of a falciform ligament were eligible for inclusion.

RESULTS

Of the 547 articles mentioning use of falciform ligament, 32 full text articles were included in this review. The majority were case reports (n = 14). The mremaining papers included retrospective analysis (n = 10), randomized control trials (n = 2), reviews (n = 3), and technique descriptions (n = 6).

CONCLUSION

The falciform ligament appears to be a safe and easily accessible natural tissue with a variety of surgical applications. It is most useful as a pedicle flap and could have benefit in foregut surgery including hepatic, pancreatic, biliary, gastric, and esophageal operations.

Effects of Kinesio taping on skin deformation during knee flexion and extension: a preliminary study

Background

Kinesio Taping (KT) is proved useful to many musculoskeletal disorders. But the mechanism remains unclear. The kinesio tape works by sticking to the skin surface. So exploring the interaction between the tape and the skin and analyzing its biomechanical influence may be an effective way to explore the mechanism of the tape.

Objectives

This study aimed to investigate the effect of Kinesio taping and taping methods on skin deformation during knee joint flexion and extension motion and further explore its possible functional mechanisms.

Methods

Ten healthy and pain-free subjects (4 males, 6 females) were recruited in this study. The skin observation area on the anterior side of the right thigh of the subjects was divided into 11 segments by 12 reflective marker points for distance measurement, from the distal knee to the proximal knee, the length of the interval was L1 to L11, and the total length was L0. Subjects were treated with no KT (NT), resting positive taping (RPT), resting negative taping (RNT), stretching positive taping (SPT), and stretching negative taping (SNT). A Qualisys infrared high-speed three-dimensional spatial coordinate capture system was used to observe changes in the length of the observed skin surface on the right anterior thigh during right knee flexion and extension in the sitting position.

Results

During right knee flexion and extension in the seated position in 10 subjects, all skin segment deformations produced significant differences between intervention groups (P < 0.05), except for L1 during flexion (P = 0.07). During right knee flexion and extension, total length, L0, and spacing lengths, L1, L6, and L11, were longer in the NT group than in all other groups. L0 and L1 were both longer in the stretched position than in the rest position; L11 also showed this trend.

Conclusions

The usage of the KT had an effect on the biomechanical changes of the skin, resulting in changes in skin deformation. I-tape, natural tension taping can shorten the skin distance between the two ends of the tape. Limb position during taping may influence the KT’s effects. However, the change in taping direction showed no significant effects on skin deformation during exercise. KT may apply a pre-stress in the biomechanics of the skin.

Outcomes of surgical management of peptic ulcer perforation using the falciform ligament: A cross-sectional study at a single centre in Vietnam

Introduction

Peptic ulcer perforation (PUP) is one of the most common critical surgical emergencies. The omentum flap is commonly used to cover a PUP. However, the omentum cannot be used in cases of severe peritonitis or previous surgical removal. This is the first study conducted in Vietnam that was designed to analyse the outcomes of patients with PUPs who were treated using the falciform ligament.

Method

In this study, we retrospectively identified 40 consecutive patients who were treated for PUP at a single high-volume centre in Vietnam from February 2018 to February 2021. Peptic ulcer perforation was measured during diagnostic evaluation based on preoperative imaging, such as X-ray, and CT scan. Patients who had malignancy, laparoscopic surgery, omentopexy and nonoperative treatment were excluded from this research.

Results

Forty patients were included; the mean age of the patients was 66.3 years (range 33–99 years), and some patients had comorbid disease (57.5%), hypertension (30%), diabetes (10%), cirrhosis (7.5%), and chronic renal failure (7.5%). The PUPs were located in the duodenum (80%), or the pyloric (15%) and prepyloric (5%) regions. The procedures used to treat the patients included duodenostomy (32.5%), gastrojejunostomy (37.5%), and antrum resection (2.5%). The average operative time was 88.6 min (45–180 min), hospital stay was 9.6 days (2–35 days), and oral intake was started at 4.1 days (3–8 days); additionally, the 30-day mortality (17.5%) and incidences of pneumonia (25%), multiorgan failure (15%), acute liver failure (5%), wound infection (7.5%), and ulcer peptic fistula (0%) were assessed. Univariate tests showed that an ASA ≥ III and comorbidities, such as pulmonary complications, liver failure and multiorgan failure, were associated with mortality. The multivariate test showed that multiorgan failure was the only factor related to mortality.

Conclusion

The falciform ligament can be efficiently used for the closure of a PUP. Although there were no instances of complication with a reperforated peptic ulcer, the mortality rate was slightly highly related to severe comorbidities and postoperative multiorgan failure.

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Peptic ulcer perforation is one of the most common surgical emergencies with an overall mortality rate is between 1.3% and 20%.

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Comorbidities, over 70 years old, having surgical therapy after 36 hours, and postoperative complications are associated with mortality.

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Using falciform ligament to replace the traditional omental patch is interesting, easy applying and efficiently in the closure of PUP.

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The mortality and complications were still high related to severe comorbidity and multiorgan failure after surgery.