Postoperative Bowel Obstruction as a Rare Complication of an Abdominal Drain

Although routine intra-abdominal drain insertion following surgery represents a common practice worldwide, its utility has been questioned during the last decades. Several comparative studies have failed to document significant benefits from routine draining, and drain insertion has been correlated with various complications as well. Drain-related complications include, but are not limited, to infection, bleeding, and tissue erosion. Herein, we present the case of a 32-year-old patient with perforated peptic ulcer and purulent peritonitis, whose postoperative course was complicated by early mechanical bowel obstruction due to an abdominal drain. A high level of clinical suspicion, along with accurate imaging diagnosis, dictated prompt removal of the drain, which resulted in immediate resolution of the patient's symptoms. We aim to increase the clinical awareness of this rare complication related to intra-abdominal drain utilization with this report.

Methamphetamine-related peptic ulcer perforation: a growing medical concern

BACKGROUND

Many studies have been done in the literature on perforations due to substance abuse, and there are limited publications on perforations related to inhaled methamphetamine. Recently, in our clinic, we observed an increase in the number of patients with perforated peptic ulcer, which we think is secondary to a significant increase in the consumption of this drug. The main purpose of this study is to determine whether the use of inhaled methamphetamine known as 'fire and ice' is a factor directly related to peptic perforation and its complications and also to determine the demographic variables of patients with peptic ulcer perforation due to this substance use, in the context of the literature.

METHODS

A retrospective study was conducted by examining the medical records of 29 gastric perforation patients who underwent surgical treatment in our clinic in 2021. Data were transferred to SPSS.23 (IBM Inc., Chicago, IL, USA) program and evaluated with statistical analysis. Normality assumptions of continuous variables were examined with Kolmogorov-Smirnov test, and variance homogeneity was examined with Levene's test. Bi-level comparisons, t-test if the data are normally distributed and Mann-Whitney U-test for bi-level comparisons where the data are not normally distributed were used. Relationships between categorical variables were examined by Chi-square test analysis. P<0.05 was accepted as the level of significance in all analyzes.

RESULTS

Twenty-nine patients were divided into two groups as methamphetamine users (n=13) and non-users (n=16). There was a statistically significant difference according to the lower age in the group using methamphetamine (31.69-48.8-P=0.025). The pres-ence of PU history differed significantly between the groups (P=0.009). Interestingly, aspartate transaminase alanine aminotransferase values were lower in substance dependents (P=0.020). Furthermore, there was a significant difference in localization between groups (P<0.001). There was no statistically significant difference between the two groups in terms of gender, clinical presentation, and other laboratory values.

CONCLUSION

Methamphetamine consumption, known as fire and ice, is an important risk factor for ulcer development and subsequent perforation, especially in young patients and long-term consumption of this narcotic substance. It has been determined that this risk factor, which is currently considered rare, has been seen in a very large number in a short time in our clinic. The use of this substance, which is considered a major social threat, is becoming more and more widespread, and this study is only a small part of the iceberg reflected in the general surgery clinic of a hospital.

Early Identification of Patients with Potential Failure of Nonoperative Management for Gastroduodenal Peptic Ulcer Perforation

INTRODUCTION

We aimed to identify objective factors associated with failure of nonoperative management (NOM) of gastroduodenal peptic ulcer perforation (GDUP) and establish a scoring model for early identification of patients in whom NOM of GDUP may fail.

METHODS

A total of 71 patients with GDUP were divided into NOM (cases of NOM success) and operation groups (cases requiring emergency operation or conversion from NOM to operation). Using logistic regression analysis, a scoring model was established based on the independent factors. The patients were stratified into low-risk and high-risk groups according to the scores.

RESULTS

Of the 71 patients, 18 and 53 were in the NOM and operation groups, respectively. Ascites in the pelvic cavity on computed tomography (CT) and sequential organ failure assessment (SOFA) score at admission were identified as independent factors for NOM failure. The scoring model was established based on the presence of ascites in the pelvic cavity on CT and SOFA score ≥2 at admission. The operation rates for GDUP were 28.6% and 86.0% in the low-risk (score, 0) and high-risk groups (scores, 2 and 4), respectively.

CONCLUSION

Our scoring model may help determine NOM failure or success in patients with GDUP and make decisions regarding initial treatment.

A comparative study on laparoscopic and open surgical approaches for perforated peptic ulcer repair: efficacy and outcomes analysis

PURPOSE

This study aimed to compare the clinical outcomes of the clinical outcomes of laparoscopic and open sutures for peptic ulcer perforation (PPU).

MATERIALS AND METHODS

PubMed, EMBASE, and Cochrane Library databases were searched for eligible studies from inception to March 31, 2023. Odds ratios (OR) and 95% confidence intervals (Cl) were also calculated. The Newcastle-Ottawa Scale (NOS) was used to evaluate the quality of the included studies. This study was performed using the Stata (V.16.0) software.

RESULTS

A total of 29 studies involving 17,228 patients were included in this study. In terms of postoperative outcomes, the laparoscopic group had a shorter postoperative hospital stay (MD = -0.29, 95%CI = -0.44 to -0.13, P = 0.00), less blood loss (MD = -0.45, 95%CI = -0.82 to -0.08, P = 0.02), fewer wound infection (OR = 0.20, 95%CI = 0.17 to 0.24, P = 0.00), fewer pneumonia (OR = 0.59, 95%CI = 0.41 to 0.87, P = 0.01), fewer respiratory complications (OR = 0.26, 95%CI = 0.13 to 0.55, P = 0.00) and lower postoperative morbidity (OR = 0.51, 95%CI = 0.33 to 0.78, P = 0.00). The laparoscopic group had a lower mortality rate (OR = 0.36, 95%CI = 0.27 to 0.49, P = 0.00) than the open group. We also found that the laparoscopic group had a higher overall complication rate than the open group (OR = 0.45, 95%CI = 0.34 to 0.60, P = 0.00).

CONCLUSION

Laparoscopic repair was associated with a lower risk of mortality than open repair in patients with PPU. Laparoscopic repair may be a better option in patients with PPU.

Predicting in-hospital mortality risk for perforated peptic ulcer surgery: the PPUMS scoring system and the benefit of laparoscopic surgery: a population-based study

BACKGROUND

The major treatment for perforated peptic ulcers (PPU) is surgery. It remains unclear which patient may not get benefit from surgery due to comorbidity. This study aimed to generate a scoring system by predicting mortality for patients with PPU who received non-operative management (NOM) and surgical treatment.

METHOD

We extracted the admission data of adult (≥ 18 years) patients with PPU disease from the NHIRD database. We randomly divided patients into 80% model derivation and 20% validation cohorts. Multivariate analysis with a logistic regression model was applied to generate the scoring system, PPUMS. We then apply the scoring system to the validation group.

RESULT

The PPUMS score ranged from 0 to 8 points, composite with age (< 45: 0 points, 45-65: 1 point, 65-80: 2 points, > 80: 3 points), and five comorbidities (congestive heart failure, severe liver disease, renal disease, history of malignancy, and obesity: 1 point each). The areas under ROC curve were 0.785 and 0.787 in the derivation and validation groups. The in-hospital mortality rates in the derivation group were 0.6% (0 points), 3.4% (1 point), 9.0% (2 points), 19.0% (3 points), 30.2% (4 points), and 45.9% when PPUMS > 4 point. Patients with PPUMS > 4 had a similar in-hospital mortality risk between the surgery group [laparotomy: odds ratio (OR) = 0.729, p = 0.320, laparoscopy: OR = 0.772, p = 0.697] and the non-surgery group. We identified similar results in the validation group.

CONCLUSION

PPUMS scoring system effectively predicts in-hospital mortality for perforated peptic ulcer patients. It factors in age and specific comorbidities is highly predictive and well-calibrated with a reliable AUC of 0.785-0.787. Surgery, no matter laparotomy or laparoscope, significantly reduced mortality for scores <  = 4. However, patients with a score > 4 did not show this difference, calling for tailored approaches to treatment based on risk assessment. Further prospective validation is suggested.

Laparoscopic versus open repair of perforated peptic ulcers: analysis of outcomes and identification of predictive factors of conversion

BACKGROUND

The surgical treatment for perforated peptic ulcers (PPUs) can be safely performed laparoscopically. This study aimed to compare the outcomes of patients who received different surgical approaches for PPU and to identify the predictive factors for conversion to open surgery.

METHODS

This retrospective study analyzed patients treated for PPUs from 2002 to 2020. Three groups were identified: a complete laparoscopic surgery group (LG), a conversion to open group (CG), and a primary open group (OG). After univariate comparisons, a multivariate analysis was conducted to identify the predictive factors for conversion.

RESULTS

Of the 175 patients that underwent surgery for PPU, 104 (59.4%) received a laparoscopic-first approach, and 27 (25.9%) required a conversion to open surgery. Patients treated directly with an open approach were older (p < 0.0001), had more comorbidities (p < 0.0001), and more frequently had a previous laparotomy (p = 0.0001). In the OG group, in-hospital mortality and ICU need were significantly higher, while the postoperative stay was longer. Previous abdominal surgery (OR 0.086, 95% CI 0.012-0.626; p = 0.015), ulcer size (OR 0.045, 95% CI 0.010-0.210; p < 0.0001), and a posterior ulcer location (OR 0.015, 95% CI 0.001-0.400; p = 0.012) were predictive factors for conversion to an open approach.

CONCLUSION

This study confirms the benefits of the laparoscopic approach for the treatment of PPUs. Previous laparotomies, a greater ulcer size, and a posterior location of the ulcer are risk factors for conversion to open surgery during laparoscopic repair.

Laparoscopic distal gastric and D1 resection for large perforated duodenal bulb peptic ulcer, with intracorporeal antecolic gastrojejunal anastomosis

BACKGROUND

Peptic ulcer perforation is a common surgical emergency and a major cause of death especially in elderly patients, despite the fact of the presence of effective drug treatments and an increased understanding of its etiology. Giant duodenal perforations, in particular, pose a significant challenge and there is scarce data regarding their optimal management. Laparoscopic surgery is advocated in the surgical treatment of perforated duodenal ulcer disease, in experienced hands.

METHODS

Herein we present an 84-year-old man with past medical history of type II diabetes mellitus and hypertension who was admitted to our Department due to epigastric pain and diffuse peritonitis. CT scan revealed the presence of a significant amount of free air and fluid in the upper abdomen secondary to a duodenal perforation.

RESULTS

The patient was taken immediately to the theater for an urgent laparoscopy. Methylene blue via the NG tube better defined the extent of the duodenal perforation which was not amenable to a primary repair. Consequently, a decision was made for a laparoscopic pancreas-sparing, ampulla preserving gastroduodenectomy with intracorporeal Billroth II gastrojejunal anastomosis. The postoperative period was uneventful and the patient was discharged on the 13th postoperative day. Histopathology revealed a large benign duodenal ulcer.

CONCLUSIONS

Although the incidence of peptic ulcer disease is decreasing, it appears that the incidence of complications is rising. Laparoscopic approach, especially when performed by laparoscopic surgery experts, could be a treatment option for difficult duodenal ulcer perforations with less pain, shorter hospital stay and reduced morbidity.

[Emergency laparoscopy in the treatment of perforated gastroduodenal ulcers]

OBJECTIVE

To compare the results of endoscopic and open treatment of perforated gastroduodenal ulcers.

MATERIAL AND METHODS

There were 445 patients with perforated gastroduodenal ulcers between 2013 and 2021. Endoscopic suturing of perforation was performed in 172 patients (38.7%), 273 ones underwent open surgery.

RESULTS

Among 172 patients scheduled for endoscopy, 160 (93.6%) ones underwent laparoscopic suturing of perforation. Morbidity rate was 5.0% (n=8), postoperative mortality rate - 1.3% (n=2). Comparison of the outcomes after laparoscopic suturing of ulcers in 160 patients and open surgery in 134 patients showed that laparoscopy was followed by 2.5 times lower incidence of complications and 3 times lower postoperative mortality.

CONCLUSION

Diagnostic laparoscopy is advisable in patients with perforated ulcers and no contraindications. In most cases, surgery can be successfully and effectively completed without conversion to laparotomy. Endoscopic closure of ulcerative defect is preferable since this procedure has certain advantages over traditional intervention, contributes to significant reduction in morbidity, mortality and hospital-stay.

Laparoscopic repair of perforated peptic ulcer - routine procedure or targeted patient selection?

INTRODUCTION

Peptic ulcer is one of the most common diseases of the proximal gastrointestinal tract. Its complications are relatively common, the most serious one being peptic ulcer perforation with the incidence of about 10 cases per 100,000 population per year and the mortality rate of 10-40%. Surgical suture via laparoscopy or laparotomy is the only treatment option. The aim of the study was to compare the short-term results of laparoscopic and open repair of acute peptic ulcer perforation and evaluate the accuracy of the Boey scoring system in the Czech population.

METHODS

Retrospective study conducted at the surgical department of the University Hospital Ostrava. The patients underwent laparoscopic or open repair of perforated peptic ulcer in 2017-2021.

RESULTS

The study included 60 patients; laparoscopic repair was performed in 43.3% of the patients, and open repair in 56.7%. Postoperative morbidity was 70.0%, mild complications were reported in 23.3% of the patients, and severe complications in 16.7%. Patients undergoing the laparoscopic repair showed a higher incidence of mild as well as severe complications (26.9% vs 20.6% and 19.2% vs 14.7%) but also a higher incidence of an uncomplicated postoperative course. Overall postoperative mortality was 30.0% (laparoscopy 15.4%, laparotomy 41.2%). The study results confirmed the estimated baseline risk of mortality based on the Boey score.

CONCLUSION

Laparoscopic repair may be the procedure of choice for patients with no or low risk factors. Patients undergoing laparoscopy showed a higher incidence of mild and severe complications. The higher mortality of patients after open repair is related to their worse initial clinical condition. Preoperative determination of mortality risk using the Boey score is accurate and appropriate in terms of choosing the surgical approach.

Duodenal ulcer perforation: A systematic literature review and narrative description of surgical techniques used to treat large duodenal defects

BACKGROUND

There is no consensus on optimal surgical treatment of large duodenal defects arising from perforated ulcers, even though such defects are challenging to repair and inadequate repair is associated with high morbidity and mortality. The aim of this study was to carry out a systematic literature review of different surgical techniques used to treat large duodenal perforations, provide a narrative description of these techniques, and propose a framework for approaching this pathology.

METHODS

PubMed/MEDLINE database was searched for articles published in English between January 1, 1970, and December 1, 2020. Studies describing surgical techniques used to treat giant duodenal ulcer perforation and their outcomes in adult patients were included. No quantitative analysis was planned because of the heterogeneity across studies.

RESULTS

Out of 960 identified records, 25 studies were eligible for inclusion. Two randomized controlled trials, one case-control trial, three cohort studies, 14 case series, and 5 case reports were included. Eight main surgical approaches are described, ranging from simple damage-control operations, such as the omental plug and triple-tube techniques, all the way to complex resections, such as gastrectomy.

CONCLUSION

Evidence on surgical treatment of large duodenal defects is of poor quality, with the majority of studies corresponding to Oxford levels 3b-4. Current evidence does not support any single surgical technique as superior in terms of morbidity or mortality, but choice of technique should be guided by several factors including location of the perforation, degree of duodenal tissue loss, hemodynamic stability of the patient, as well as expertise of the operating surgeon.

LEVEL OF EVIDENCE

SR with more than two negative criteria, Level IV.

Rare case of dual gastrointestinal perforations

A 49-year-old man presented to the nearest emergency department profoundly septic with significantly raised inflammatory markers. He had a background of floor of mouth invasive squamous cell carcinoma for which he underwent complex head and neck surgery followed by adjuvant radiotherapy and insertion of a percutaneous gastrostomy tube for feeding. He experienced 3 weeks of retching, cough and malaise. Imaging revealed both an oesophageal perforation and perforated duodenal ulcer, presumed secondary to oesophageal stricturing from his prior surgery and radiotherapy.

Gastric Perforation due to Iatrogenic Immunodeficiency-associated Lymphoproliferative Disorder during the Treatment of Rheumatoid Arthritis

A 71-year-old woman being treated with methotrexate (MTX) and tacrolimus (TAC) for rheumatoid arthritis (RA) was admitted to our hospital and underwent surgery for gastric perforation and peritonitis. An endoscopic examination six days post-surgery showed an extensive ulcer in the stomach, and a biopsy revealed diffused large B-cell lymphoma. We diagnosed her with immunodeficiency-associated lymphoproliferative disorder (LPD) and discontinued the MTX and TAC. She underwent gastrectomy due to stenosis approximately two months after the first operation, but the histopathological findings of lymphoma had disappeared. LPD should be considered as a potential cause of gastric perforation during RA treatment.

[Gastric perforation in Eastern European economic migrants]

The general prevalence of perforated peptic ulcers is decreasing and they are, therefore, more likely to be missed. In our hospital, Eastern European migrants are overrepresented in the population of patients with perforated gastric peptic ulcers; due to a higher prevalence of Helicobacter pylori in Eastern Europe, they have a higher chance of developing gastric peptic ulcers than patients of Dutch origin. Treatment is hampered by the language barrier and low compliance rates, with patients often leaving hospital against medical advice and not showing up for follow-up appointments. These patients should, therefore, be informed by an interpreter, so that they are well educated about the disease and its treatment. Furthermore, we advise determination of the presence of H. pylori in these patients either during or directly after surgery, and, if necessary, empirical eradication of the bacteria.

Diverticular Perforation: A Fatal Complication to Forestall in Cushing Syndrome

CONTEXT

Patients taking exogenous glucocorticoids are at risk for gastrointestinal (GI) complications, including peptic ulcer disease with perforation and gastric bleeding. However, little is known about the GI comorbidity in patients with endogenous hypercortisolemia.

CASE DESCRIPTIONS

We describe six patients with endogenous Cushing syndrome (CS) who developed sudden perforation of colonic diverticula necessitating urgent exploratory laparotomy. Most of these patients shared the following features of CS: skin thinning, severe hypercortisolemia (24-hour urinary free cortisol ≥10 times the upper limit of normal), ectopic secretion of ACTH, and severe hypokalemia. At the time of diagnosis of diverticular perforation (DP), these patients had minimal signs of peritonitis and lacked fever or marked leukocytosis. The diagnosis of DP was established by having a low threshold for obtaining an imaging study for evaluation of nonspecific abdominal pain.

CONCLUSIONS

Patients with CS can develop spontaneous surgical abdomen with rapid decompensation within hours. Prompt recognition is critical in the successful treatment of these patients.

Time latencies of Helicobacter pylori eradication after peptic ulcer and risk of recurrent ulcer, ulcer adverse events, and gastric cancer: a population-based cohort study

BACKGROUND AND AIMS

Helicobacter pylori is associated with peptic ulcer disease and gastric cancer. Therefore we wanted to test how various lengths of delays in H pylori eradication therapy influence the risk of recurrent peptic ulcer, ulcer adverse events, and gastric cancer.

METHODS

This population-based nationwide Swedish cohort study included 29,032 patients receiving H pylori eradication therapy after peptic ulcer disease in 2005 to 2013. Predefined time intervals between date of peptic ulcer diagnosis and date of eradication therapy were analyzed in relation to study outcomes. Cox regression provided hazard ratios (HRs) and 95% confidence intervals (95% CIs), adjusted for age, sex, comorbidity, history of ulcer disease, use of ulcerogenic drugs, and use of proton pump inhibitors (PPIs).

RESULTS

Compared with eradication therapy within 7 days of peptic ulcer diagnosis, eradication therapy within 8 to 30, 31 to 60, 61 to 365, and >365 days corresponded with HRs of recurrent ulcer of 1.17 (95% CI, 1.08-1.25), 2.37 (95% CI, 2.16-2.59), 2.96 (95% CI, 2.76-3.16), and 3.55 (95% CI, 3.33-3.79), respectively. The corresponding HRs for complicated ulcer were 1.55 (95% CI, 1.35-1.78), 3.19 (95% CI, 2.69-3.78), 4.00 (95% CI, 3.51-4.55), and 6.14, (95% CI, 5.47-6.89), respectively. For gastric cancer the corresponding HRs were .85 (95% CI, .32-2.23), 1.31 (95% CI, .31-5.54), 3.64 (95% CI, 1.55-8.56), and 4.71 (95% CI, 2.36-9.38), respectively.

CONCLUSIONS

Delays in H pylori eradication therapy after peptic ulcer diagnosis time-dependently increase the risk of recurrent ulcer, even more so for complicated ulcer, starting from delays of 8 to 30 days.

Perforated Duodenal Ulcer and Cigarette Smoking

Whilst the association between smoking and peptic ulceration has been reported previously, the relationship between smoking and the complications of ulcers, such as perforation, bleeding or acute painful exacerbation, has not been examined. In a retrospective study comparing 275 emergency admissions for peptic ulcer with 275 controls, cigarette smoking was significantly more common only in those with a perforated duodenal ulcer. Of 128 patients with perforated duodenal ulcers, 110 (86%) were cigarette smokers compared with 65 (51%) of the 128 matched controls (χ2, P<0.01). Cigarette smoking in patients with bleeding or acutely exacerbated ulcers was not significantly more common than in controls. These findings strongly suggest a particular association between smoking and perforated duodenal ulcer.

Marginal ulcer perforation: a single center experience

PURPOSE

Marginal ulcer (MU) is defined as ulcer on the jejunal side of the gastrojejunostomy (GJ) anastomosis. Most MUs are managed medically but those with complications like bleeding or perforation require intervention. It is recommended that GJ anastomosis be revised in patients with MU perforation (MUP). The aim of this case series is to study the clinical presentation and management of MUP.

METHODS

Three hundred and thirty-two patients who underwent emergency surgery for perforated peptic ulcer at a single center were studied over a period of 5 years.

RESULTS

Nine patients (2.7 %) presented with MUP. GJ was previously done for either complicated peptic ulcer (n = 4) or for suspected gastric malignancy (n = 5). Two patients had previously completed H. pylori therapy. None of the patients presented with septic shock. MU was on the jejunal side of GJ in all patients. The median MUP size was 10 mm. Four patients (44.4 %) had omental patch repair, three (33.3 %) had primary closure, and one each had revision of GJ and jejunal serosal patch repair. There were no leaks, intra-abdominal abscess or reoperation and no malignancies.

CONCLUSION

MUP patients do not present with septic shock. Omental patch repair or primary closure is sufficient enough. Revision of Billroth-II-GJ into Roux-en-Y-GJ is not mandatory.

Perforated gastric ulcer in severe dengue infection: A case report

Abdominal pain is one of the common presentations in severe dengue infection. We report a rare case of perforated gastric ulcer in a young man diagnosed with severe dengue infection and the challenges we faced in managing this patient. Perforated gastric ulcer need to be considered if there are signs of peritonitis and persistent abdominal pain that does not conform to the natural history of dengue. Proper imaging and early surgical intervention in perforated gastric ulcer is vital in preventing further complication and reducing the risk of mortality.

[SURGICAL TREATMENT OF COMPLICATED GASTRODUODENAL ULCER]

Results of operative treatment of 437 patients with complicated gastroduodenal ulcer were summarized. The modern views on the problem of conservative therapy for gas- troduodenal ulcer were presented. A rational individual approach with a certain terms is necessary for conservative treatment of gastroduodenal ulcer. A real way for improve- ment of the patients treatment results--it is a combination of effective conservative treatment with a timely established indications for a planned operative treatment before dangerous complications occur.

DIAGNOSTICS AND TREATMENT OF PERFORATED PYLORODUODENUM ULCERS IN WOMEN

The results of treatment of 75 women with perforated ulcers have been studied. There were prevailed women of middle and elderly age groups among patients who underwent surgery. A wound closure of perforated opening and abdominal sanation were performed by laparoscopic means in 30,7% of patients and using midline laparotomy in 29,3% cases. There were carried out the laparoscopic sanation of the abdominal cavity and the wound closure of perforated ulcer from mini-access using the set of mini-assistant in 10,7% patients. Radical operations were applied in 16% cases. The early postoperative complications took place in 8,1% of the patients, the rate of lethality was 4,0%. The long-term results were evaluated and considered as good in 55,5% women, satisfactory — in 30,1% and unsatisfactory — in 14,2% cases.

Perforated duodenal ulcer: An unusual manifestation of allergic eosinophilic gastroenteritis

Spontaneous perforation of a duodenal ulcer secondary to allergic eosinophilic gastroenteritis (EGE) has not been previously reported. We present such a case in a teenager who presented with peritonitis. After exploration and operative repair of his ulcer, he continued to experience intermittent abdominal pain, and further evaluation revealed eosinophilic gastroenteritis in the setting of multiple food allergies. His EGE resolved after adhering to a restrictive diet. Both duodenal ulcers and EGE are very rarely seen in pediatric patients. EGE has a variable presentation depending on the layer(s) of bowel wall affected and the segment of the gastrointestinal tract that is involved. Once diagnosed, it may respond to dietary changes in patients with recognized food allergies, or to steroids in patients in whom an underlying cause is not identified. Our case highlights the need to keep EGE in the differential diagnosis when treating pediatric patients with duodenal ulcers. The epidemiology, pathophysiology, and treatment of EGE are also discussed, along with a review of the current literature.

Perforated peptic ulcer

Perforated peptic ulcer is a common emergency condition worldwide, with associated mortality rates of up to 30%. A scarcity of high-quality studies about the condition limits the knowledge base for clinical decision making, but a few published randomised trials are available. Although Helicobacter pylori and use of non-steroidal anti-inflammatory drugs are common causes, demographic differences in age, sex, perforation location, and underlying causes exist between countries, and mortality rates also vary. Clinical prediction rules are used, but accuracy varies with study population. Early surgery, either by laparoscopic or open repair, and proper sepsis management are essential for good outcome. Selected patients can be managed non-operatively or with novel endoscopic approaches, but validation of such methods in trials is needed. Quality of care, sepsis care bundles, and postoperative monitoring need further assessment. Adequate trials with low risk of bias are urgently needed to provide better evidence. We summarise the evidence for perforated peptic ulcer management and identify directions for future clinical research.

Valentino appendix: a report of 3 cases

We present three cases of young male patients with perforated duodenal ulcer that were diagnosed and treated as appendicitis with appendectomy. They presented with peritonitis and were treated accordingly. Because of the misdiagnosis, their hospital course was significantly prolonged. This morbidity could have been avoided by careful history-taking, examination and per-operative findings.

[Management of perforative gastroduodenal ulcer]

AIM

To study the immediate results of surgical treatment of patients with perforative gastroduodenal ulcer.

MATERIAL AND METHODS

It was analyzed immediate results of surgical treatment of 646 patients with perforative gastroduodenal ulcer. Ulcer suturing predominated as surgical technique (358 patients, 55.5%), in other observations there were different types of vagotomy (215 cases, 33.3%), partial gastrectomy in 73 (11.2%) patients.

RESULTS

In early postoperative period 36 (5.62%)patients died, incidence of complications was 6.2%. Following aspects effect on choice of surgical techbique including laoarotomy or minimally invasive approach, conventional suturing, vagotomy, partial gastrectomy: 1. presence of shock or unstable hemodynamics; 2. life-threating comorbidities (ASA class 3 and higher); 3. degree of abdominal bacterial contamination; 4. pre-hospital duration of disease; 5. dimension and type of ulcer; 6. ulcerative history or intraoperative evidence of chronic ulcer. Implementation or absolute predominance of surgery of the same type (suturing of perforative ulcer) leads to great number of poor long-term results (up to 60-70%) and requires repeated interventions.

Gastrojejunal Anastomosis Complications and Their Management after Laparoscopic Roux-en-Y Gastric Bypass

BACKGROUND

Complications at the gastrojejunal anastomosis after laparoscopic Roux-en-Y gastric bypass (LRYGB) are challenging in terms of diagnosis, therapy, and prevention. This study aims at identifying these complications and discussing their management.

METHODS

Data of 228 patients who underwent a LRYGB between October 2008 and December 2011 were reviewed retrospectively to evaluate the frequency and treatment of complications such as stenoses, marginal ulcers, perforated marginal ulcers, or anastomotic leaks related to the operation.

RESULTS

Follow-up information was available for 209 patients (91.7%) with a median follow-up of 38 months (range 24-62 months). Of these patients 16 patients (7.7%) experienced complications at the gastrojejunostomy. Four patients (1.9%) had stenoses and 12 patients (5.7%) marginal ulcers, one of them with perforation (0.5%). No anastomotic leaks were reported. One case with perforated ulcer and one with recurrent ulcers required surgical revision.

CONCLUSION

Gastrojejunal anastomotic complications are frequent and occur within the first few days or up to several years after surgery. Stenoses or marginal ulcers are usually successfully treated nonoperatively. Laparoscopic repair, meanwhile, is an appropriate therapeutic option for perforated ulcers.

Acute abdominal complications following hip surgery

Hip surgeries are some of the most common and successful orthopedic procedures. Although rarely, abdominal complications do occur and are associated with unfavorable outcomes.We aimed to identify and describe the severe abdominal complications that appear in patients under-going elective or traumatic hip surgery. A four year retrospective electronic database research identified 408 elective primary hip replacements,51 hip revisions and 1040 intra and extracapsular proximal femur fractures. Out of these, three males and 4 females between 64 - 84 years old were identified to have developed acute abdominal complications: perforated acute ulcer (3),acute cholecystitis (2), volvulus (1), toxic megacolon with peritonitis (1) and acute colonic pseudo-obstruction (1).Complications debuted 3 - 10 days after index orthopedic surgery. Acute perioperative abdominal complications are rarely encountered during orthopedic surgery. When these do occur, they do so almost exclusively in patients with hippathology, comorbidities and most often lead to life threatening situations. We thus emphasize the need for early identification and appropriate management by both orthopedic and general surgery doctors in order to improve patient safety.

[Clinical-epidemiological aspects of gastric and duodenum ulcer]

An analysis of reporting and statistical data showed the considerable changes in clinical-epidemiological indices of gastric and duodenum ulcer at the period from 1998 to 2012. The prevalence of the disease and the number of primary patients decreased in 2-3 times. The reduction of the rate of perforations and ulcerous bleeding had been observed. However, the authors noted, that a tendency of frequency of occurrence increased and efficacy indices reduced in the last years. The rate of postoperative lethality raised in the cases of perforated ulcer. On this basis, the authors recommend to reconsider the existing opinion about further extension of out-patient treatment of patients with given pathology.

[Laparoscopic treatment of perforated ulcers]

It was done comparative analysis the results of different treatment options using of laparoscopic treatment of 331 patients with perforated ulcers. It was defined that postoperative complications frequency is increased to 1.6% in case of perforated ulcers suturing with diameter to 0.7 cm. This indication is increased to 7.1% in case of perforated ulcers suturing and plugging by greater omentum with holes diameter to 1.0 cm. The complications are absent in case of perforated ulcer excision with subsequent vagotomy and pyloroplasty.

[Surgical tactics at "difficult" perforative duodenal ulcers]

Bacteriological research of abdominal cavities exsudate is conducted to 264 patients on perforative duodenal ulcers and the dynamics of peritonitis motion is studied in a postoperative period. It is set that already hour-long after the perforation of duodenal ulcer, according to information of peritoneal maintenance pH-metry and it's bacteriologic research, the optimum conditions for progress of inflammatory and infectious factors are created in an abdominal cavity. Therefore a formal term from the moment of perforation can not be the index of degree of inflammation (bacterial contamination) of peritoneum. The methods of duodenoplasty are improved at the giant perforative ulcers of duodenum and ulcers, combined with tubular stenosis of duodenum, allowed to avoid development of purulent-septic postoperative complications through insolvency of stitches and severe motor function disturbances.

[Clinical introduction of the method of the abdominal cavity infiltrate dissection with saving of anatomic integrity and functional capacity of organs, included in the inflammatory process]

The results of application of the tissue dissection method and hemostasis performance while operation for the abdominal organs acute diseases were summarized. The proposed method introduction have permitted to reduce the intraoperative complications rate from 66.6%--in a control group to 12.2%--in the main group; postoperative complications--from 21.2 to 1.7%, postoperative lethality--from 7.4 to 1.7%.

Laparoscopic treatment of perforated duodenal ulcer -- a multicenter study

AIM

The aim of this study is to evaluate the results of the laparoscopic treatment of perforated duodenal ulcer performed in 6 Romanian surgical centres with experience in the field of laparoscopic surgery.

MATERIAL AND METHOD

Between 1996 and 2005, 186 patients with perforated duodenal ulcer were operated on in the centers participating in this retrospective study, all patients being ASA I-II. Thirty-nine patients (20.0%) presented mild peritonitis, 120 (64.5%) medium peritonitis and 27 (15.5%) severe (20.0%) simple suture was performed, in 110 (59.1%) suture with epiplonoplasty, for 1 (0.5%) only epiplonoplasty and 1 (0.5%) underwent excision of the perforation and suture.

RESULTS

The operative time was between 30-120 minutes, with an average of 75 minutes. No death was noted. Average hospitalization time was 6 days, with periods varying between 3 and 18 days. Postoperative complications included: 5 patients (2,6%) presented infections of the abdominal walls, 1 patient (0.5%) duodenal fistula, 1 patient (0.5%) intra-abdominal abscess, 1 patient (0.5%) a superior digestive hemorrhage by "mirrored ulcer" and 1 patient (0.5%) duodenal stenosis 6 months after operation. The patients were administered 50% less analgesics, used 70% less dressings, 30% less antibiotics and had 60% less complications in comparison with those operated by the classical approach.

CONCLUSION

The laparoscopic approach of perforated duodenal ulcer constitutes the first choice for patients without important co-morbidities, allowing a quick recovery and a significant reduction in the consumption of analgesics, antibiotics and dressing materials.

Laparoscopic approach in abdominal emergencies: a 5-year experience at a single center

BACKGROUND

Laparoscopy is ever more common in both elective and emergency surgery. In fact, in abdominal emergencies it enables the resolution of preoperative diagnostic doubts as well as treatment of the underlying disease. We present a retrospective study of the results of a 5-year experience at a single center.

PATIENTS AND METHODS

Between September 2006 and August 2011, 961 patients were treated via laparoscopy, including 486 emergency cases (15 gastroduodenal perforation; 165 acute cholecystitis; 255 acute appendicitis; 15 pelvic inflammatory disease and non-specific abdominal pain [NSAP]; 36 small bowel obstruction). All procedures were conducted by a team trained in laparoscopic surgery.

RESULTS

The conversion rate was 22/486 patients (4.53%). A definitive laparoscopic diagnosis was possible in over 96% of cases, and definitive treatment via laparoscopy was possible in most of these.

CONCLUSIONS

Our own experience confirms the literature evidence that laparoscopy is a valid option in the surgical treatment of abdominal emergencies. In any case, it must be performed by a dedicated and highly experienced team. Correct patient selection is also important, to enable the most suitable approach for each given situation.

Perforated peptic ulcer disease in Zewditu Hospital

BACKGROUND

Peptic ulcer perforation is a serious complication of peptic ulcer disease with a significant morbidity and mortality.

OBJECTIVE

To evaluate 76 patients operated for peptic ulcer perforation and analyse the associated factors in Zewditu Memorial Hospital, Addis Ababa from September 2006 to August 2008.

PATIENTS AND METHODS

A retrospective analysis of medical records of 76 patients who were operated up on for perforated peptic ulcer over a two year period (2006-2008).

RESULTS

The male to female ratio was 6.6:1 with a mean age being 31.5 years. The most common presenting symptom was abdominal pain in 76 (100%) patients. History of smoking and khat chewing was documented in 53/64 (82.8%) and 48/64 (75%) of the patients respectively. Twenty five per cent of the patients gave no history of previous peptic ulcer disease. Seventy patients (92.1%) presented after 48 hours of their illness. The mean hospital stay was 14.5 days. Leucocytosis was found in 31.6% of the cases. Sixty five (85.5%) patients had duodenal ulcer perforation. Postoperative complications occurred in 24 (31.6%) patients. Twelve (15.8%) patients died in the hospital.

CONCLUSION

Early presentation of patients and change in life style may reduce morbidity and mortality in patients with peptic ulcer perforation.

[Perforative gastroduodenal ulcers]

Treatment results of 986 patients with perforative gastroduodenal ulcers were analyzed. The sequence of surgeon's acts was diagnostically effective in 99.5%. 776 (78.7%) of patients presented with duodenal ulcer; 210 (21.3%) had gastric ulcer. Ulcer closure was performed in 934 (94.7%) cases; gastric resection was made in 52 (5.3%) cases. Postoperative lethality rate was 4.3%. Tissue destruction proved to be partly connected with the level of the connective tissue metabolites in blood. The balance of factors of aggression and defense (Helicobacter invasion, level of mucus formation, mucosal leucocytal infiltration, acid level in stomach and level of necrosis factor in blood) was registered in long-term follow-up in dependence of the operation performed. Ulcer perforation recurrence was registered in 18.8% of simple closure cases and in 3.8% of patients after gastric resection.

Therapeutic attitude in perforated stress ulcer

There are medical conditions where the etiology is not at the level of digestive system, but as a result of a distant lesion, determined by head trauma. The latter is a severe impact on the whole body, not only locally; it produces damages in the gastro-duodenal area mainly as acute stress ulcer.

MATERIAL AND METHODS

Our study includes 4 cases of patients with multiple trauma, admitted in the "St. Pantelimon" Emergency Hospital, where, despite medication, they subsequently developed stress ulcer (Cushing ulcer). Laboratory tests were followed in the development the level of leukocytes, ESR(erythrocyte sedimentation rate) and abdominal ultrasound. Around the fifth day it was observed that the level of the leukocytes were high (between 15000-20000/microl).

RESULTS

ESR between 40-70mm/hour and ultrasound showed fluid in peritoneal cavity, mainly in subhepatic space (Morison's pouch). A positive radiological result highlight the crescent transparency (mesogastric pneumoperitoneum) in dorsal decubitus position, lateral incidence (pacients that could not be mobilised and the radiologic exam was made in intensive care bed). On the group of four patients studied with multiple trauma and Cushing ulcer perforation, it was laparoscopically intervined in order to reduce the negativ effects of combined anesthesic and surgical trauma on an already fragile status.

CONCLUSIONS

The study showed that emergency laparoscopy in patients with multiple trauma is a successful approach in it's minimally invasivity, being a diagnosis and therapeutic first option in acute abdominal conditions in these patients.

Helicobacter pylori is not the predominant etiology for peptic ulcers requiring operation

As the number of patients requiring operation for peptic ulcer disease (PUD) declines, presumed contemporary ulcer etiology has largely been derived from medically treated patients not subjected to surgery. The purpose of this study was to examine the specific causes of PUD in patients requiring surgery. Our Acute Care Surgical Service registry was reviewed for patients operated on for complications of PUD from 2004 to 2009. Emphasis was placed on individual etiologic factors for PUD. There were 128 patients (52% male, 81% white) who underwent emergency operation including: simple patch closure (n = 61, 48%); gastric resection (n = 22, 17%); gastric resection with vagotomy (n = 21, 16%); vagotomy and pyloroplasty (n = 18, 14%); or other procedures (n = 6, 5%). Complications necessitating operation were perforation (n = 79, 62%); bleeding (n = 29, 23%); obstruction (n = 12, 9%); and intractability (n = 8, 6%). Perioperative mortality was 12.5 per cent. Risk factors for PUD included tobacco use (50%), alcohol abuse (34%), and steroids (21%). Nonsteroidal anti-inflammatory use was confirmed in 68 (53%) patients. Of the 128 patients, 82 (64%) were tested for Helicobacter pylori, 33 (40%) of which were positive and 49 (60%) negative. Helicobacter pylori, thus, was the confirmed ulcer etiology in only 26 per cent of cases. Unlike contemporary series of medically treated PUD, Helicobacter pylori may not be the predominant etiologic factor in patients who experience complications requiring surgery. A "traditional" surgical approach with liberal use of vagotomy, not antibiotic triple therapy, may well be the preferred treatment consideration in such cases.

[Clinical and radiation diagnosis of circumscribed peritonitis complicating duodenal perforation]

This paper deals with the results of ultrasound (US) and multislice computed tomography (MSCT) in patients with perforated duodenal ulcer in different periods after the onset of the disease, with varying clinical manifestations, and in the postoperative period. A comparative analysis of the results of radiation studies has indicated that X-ray study is a basic technique that defines treatment policy in the early development periods of perforation; US study (USS) reveals a change in the duodenum, fluid and infiltration outside the duodenum. As circumscribed peritonitis progresses, USS allows the diagnosis of abdominal abscesses and infiltrations. Out of the radiation techniques, MSCT is of most importance in the diagnosis of interintestinal abscesses and in the determination of syntopy of purulent cavities.

[Diaphragmatic hernia complicated with perforated stomach during pregnancy]

Diaphragmatic hernia complicating pregnancy is rare and results in a high mortality rate, if early surgical intervention is not undertaken. We report a case of a woman at 32 week's gestation who was admitted to our hospital due to severe epigastralgia. Diaphragmatic relaxation had been pointed out since her birth. The patient was initially diagnosed with acute gastritis, but she developed acute respiratory insufficiency on day 3 of hospitalization. Chest X-ray and computed tomography showed niveau in the left pleural cavity. She was treated with chest tube drainage and an emergency caesarean was performed. The next day, gastric fiberscope demonstrated perforation of gastric ulcer in the left hemithorax. She was diagnosed as having diaphragmatic hernia complicated by a perforated stomach. Emergency thoracotomy was carried out and primary repair of both stomach and diaphragma was performed.

Perforated peptic ulcer (PPU) in pregnancy during Ramadan fasting

BACKGROUND

Perforated Peptic Ulcer (PPU) is extremely rare in pregnancy. We report a case of perforated peptic ulcer in pregnancy during Ramadan fasting.

PATIENT AND METHODS

The patient is a 16 years old primigravida who presented with features of peritonitis at 28weeks of gestation while fasting during Ramadan. Ultrasound scan reported a singleton live fetus at 28 weeks gestation. At laparotomy via upper midline incision; a 1 cm roundish perforation located on the duodenum anteriorly was found with about a litre of gastric juice mixed with blood and food particles in the peritoneal cavity. The perforation was close transversely with omental patch (Modified Graham's patch) and peritoneal lavage done with warm saline. She had a preterm delivery of a 1 kg baby 3 days post-operatively by a spontaneous vaginal delivery, but the baby died 3 days later.

CONCLUSIONS

Perforated Peptic Ulcer(PPU) though rare in pregnancy can occur and fasting can be a risk factor.

Late results of a simple closure technique and Helicobacter pylori eradication in duodenal ulcer perforation

BACKGROUND AND AIM

The aim of this study is to determine the incidence of Helicobacter pylori (H. pylori) in patients operated on for duodenal ulcer perforation and to evaluate the late results of a simple closure technique in patients positive and negative for H. pylori.

METHODS

The data of 84 patients who underwent simple closure for duodenal ulcer between 2003-2007 were retrospectively studied. Antral biopsy material taken from all patients during laparotomy was studied with the rapid urease test and the patients were then separated into 2 groups. Group 1 (H. Pylori positive) received postoperative H. pylori eradication treatment, and Group 2 (H. pylori negative) received only lansaprasol treatment after surgery. All patients were evaluated with upper gastrointestinal endoscopy on the 6th and 14th postoperative weeks. Primary treatment failure was considered in patients who had non-healing ulcers after 14 weeks. Patients with healed ulcers were scheduled for annual examinations. The results were compared between the groups.

RESULTS

The rate of H. pylori infection in duodenal ulcer perforation was found to be 80.9%. Ulcer healing rates on the postoperative 6th and 14th weeks were 88.2% and 97.5% in the first group, and 68.8% and 81.2% in the second group, respectively. Mean postoperative follow-up was 41.28 +/- 17.63 (range 17-73) months. Ulcer recurrence rate was found to be 4.54% in Group 1 and 30.76% in group 2 (p = 0.012).

CONCLUSIONS

All patients with a perforated peptic ulcer should be treated with simple closure of the perforation followed by medical therapy aimed at healing the ulcer. We believe that H. pylori negative patients have more risk of recurrence and such patients require close postoperative follow-up.

Perforated peptic ulcer disease: a review of history and treatment

BACKGROUND

In the last one hundred years much has been written on peptic ulcer disease and the treatment options for one of its most common complications: perforation. The reason for reviewing the literature was evaluating most common ideas on how to treat perforated peptic ulcers (PPU) in general, opinions on conservative treatment and surgical treatment and summarizing ideas about necessary pre-, per- and postoperative proceedings.

METHOD

All relevant articles found by Medline, Ovid and PubMed search were used.

RESULTS

A hundred articles written between 1929 and 2009 were reviewed. Of these, 9 were about the history of treatment, 7 about conservative treatment, and 26 were about the surgical procedure of which 8 were addressing laparoscopic correction. Overall there is no consensus, but some advice is given. For conservative treatment there are only a few indications. Use of an omental patch is recommended, irrigation and drainage are not. Laparoscopic correction of PPU as well as for definitive ulcer surgery has many advantages.

CONCLUSIONS

Surgery for PPU is still a subject of debate despite more than an era of published expertise, indicating the need for establishing guidelines.

[Postulcerorhaphic syndrome: causes of the development and pathogenetic forms]

The article deals with the question of consequences of suturing perforating pyloroduodenal ulcer in late terms in 355 patients. Marking out the postulcerorhaphic syndrome which complicated the course of the ulcer disease in 24.5% of cases and requires the determination of early indications to reoperation was grounded.