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.

Unusual case of retroperitoneal hematoma and duodenal ulcerative bleeding after nephrectomy: Case report

RATIONALE

Retroperitoneal hematomas are relatively common in patients undergoing nephrectomy. Herein, we report an unusual case involving a giant retroperitoneal hematoma and subsequent duodenal ulcerative bleeding following a radical nephrectomy.

PATIENT CONCERNS

A 77-year-old woman was admitted to our hospital for lower back pain, and she had severe right hydronephrosis and a urinary tract infection.

DIAGNOSES

The patient was diagnosed and confirmed as high-grade urothelial carcinoma.

INTERVENTIONS

After ineffective conservative treatments, a right radical nephrectomy and ureteral stump resection were performed. The patient received proton pump inhibitors to prevent stress ulcer formation and bleeding. On the first day post-surgery, she had normal gastrointestinal (GI) endoscopy findings. On the second day post-surgery, abdominal computed tomography revealed a retroperitoneal hematoma. Notably, 14 days post-surgery, massive GI bleeding occurred, and GI endoscopy identified an almost perforated ulcer in the bulbar and descending duodenum.

OUTCOMES

The patient died on day 15 after surgery.

LESSONS

Duodenal ulceration and bleeding might occur following a retroperitoneal hematoma in patients treated with nephrectomy. Timely intervention may prevent duodenal ulcers and complications, and thus could be a promising life-saving intercession.

Successful endoscopic combined with endovascular haemostasis of a ruptured pseudoaneurysm of the duodenal bulb: A case report

Pseudoaneurysms are uncommon but their rupture and bleeding can lead to serious complications and be fatal. We present here a case of a man in his late 70s who was transferred to our hospital with persistent gastrointestinal bleeding. One month prior to his admission, he had undergone surgery for a fracture to his left knee. Endoscopic examination found pulsating blood vessels on a duodenal ulcer, which suddenly ruptured and caused significant bleeding. Immediate endoscopic haemostasis was administered and the bleeding decreased. Considering the high rate of rebleeding that may occur with a pseudoaneurysm, the patient underwent interventional radiology that culminated in a diagnosis of a pseudoaneurysm originating from gastroduodenal artery (GDA); successful embolization was achieved. Tests showed that the patient had Helicobacter pylori infection. We hypothesised that the H. pylori infection had led to the occurrence of the duodenal bulb ulcer, and the patient's left knee fracture and surgery a month previously had contributed to this predisposition for a pseudoaneurysm.

Gastric, Duodenal, and Small Bowel Emergencies

Gastric and small bowel emergencies are often seen in the emergency department and require rapid assessment and intervention as patients can deteriorate quickly. Some of the more frequently seen gastric emergencies include gastric volvulus and peptic ulcer disease, which can present with ischemia, strangulation, perforation, or severe bleeding. Swift diagnosis is crucial to ensuring the proper management whether that is endoscopic or with surgical exploration. Perforated peptic ulcers that are not contained will require surgical intervention, whereas bleeding ulcers can often be controlled with endoscopic interventions.

Pancreas-sparing partial duodenectomy as an alternative to emergency pancreaticoduodenectomy for a major duodenal perforation: a case report

A 71-year-old woman underwent endoscopic submucosal dissection for early duodenal cancer at the second portion of the duodenum and developed acute peritonitis due to delayed duodenal perforation. Emergency laparotomy was performed. A huge perforation formed at the descending duodenum without ampulla involvement. Pancreas-sparing partial duodenectomy (PPD) with gastrojejunostomy was performed (250 min operative time) with 50 mL of intraoperative blood loss. She required intensive care for 3 days and was discharged on postoperative day 21 with no severe complications. Emergency treatment for a major duodenal injury or perforation remains challenging because of high morbidity and mortality. An appropriate treatment should be considered according to the nature of the defect. Although PPD is an acceptable procedure for patients with a duodenal neoplasm, its use in emergency surgery is rarely reported. PPD is more reliable than primary repair or anastomosis using a jejunal wall, and less invasive than pancreaticoduodenectomy, for emergency treatment. We performed PPD in this patient because the duodenal perforation was too large to reconstruct and did not involve the ampulla. PPD can be a safe and feasible alternative surgical procedure to pancreaticoduodenectomy for a major duodenal perforation, especially in patients with a duodenal perforation that does not involve the ampulla.

Concurrent laparoscopic highly selective vagotomy with closure of duodenal ulcer perforations show good clinical results as primary repair alone

OBJECTIVE

To compare clinical and operative results between laparoscopic primary repair (LPR) alone and LPR with highly selective vagotomy (LPR-HSV) in patients with duodenal ulcer perforation.

METHODS

Clinical data from patients who underwent either LPR or LPR-HSV by resecting both sides of the neurovascular bundle using an ultrasonic or bipolar electrosurgical device for duodenal ulcer perforations, between 2010 and 2020, were retrospectively collected. Between-group differences in continuous and categorical variables were statistically analysed.

RESULTS

Data from 184 patients (mean age, 49.6 years), who underwent either LPR (n = 132) or LPR-HSV (n = 52) were included. The mean operation time was significantly longer in the LPR-HSV group (116.5 ± 39.8 min) than in the LPR group (91.2 ± 33.3 min). Hospital stay was significantly shorter in the LPR-HSV group (8.6 ± 2.6 days) versus the LPR group (11.3 ± 7.1 days). The mean postoperative day of starting soft fluid diet was also significantly shorter in the LPR-HSV group (4.5 ± 1.4 days) than in the LPR group (5.6 ± 4 days). No between-group difference in morbidity rate was observed. The learning curve of the HSV procedure showed a stable procedure time after 10 operations.

CONCLUSIONS

LPR with HSV may be a safe and feasible procedure for selective cases who are at high risk for ulcer recurrence.

Comparison between traumatic and atraumatic over-the-scope clips in patients with duodenal ulcer bleeding: a retrospective analysis with propensity score-based matching

BACKGROUND AND AIMS

Over-the-scope clips (OTSCs) substantially improved the endoscopic armamentarium for the treatment of severe GI bleeding and can potentially overcome limitations of standard clips. Data indicate a superiority of OTSCs in hemostasis as first- and second-line therapy. However, the impact of the OTSC designs, in particular the traumatic (-t) or atraumatic (-a) type, in duodenal ulcer bleeding has not been analyzed so far.

METHODS

This was a retrospective analysis of a prospective collected database from 2009 to 2020 of 6 German endoscopic centers. All patients who underwent emergency endoscopy and were treated using an OTSC for duodenal ulcer bleeding were included. OTSC-t and OTSC-a patients were compared by the Fisher exact test, χ2 test, or Mann-Whitney U test as appropriate. A propensity score-based 1:1 matching was performed to obtain equal distribution of baseline characteristics in both groups.

RESULTS

The entire cohort comprised 173 patients (93 OTSC-a, 80 OTSC-t). Age, gender, anticoagulant therapy, Rockall score, and treatment regimen had similar distributions in the 2 groups. However, the OTSC-t group showed significantly more active bleeding ulcers (Forrest Ia/b). Matching identified 132 patients (66 in both groups) with comparable baseline characteristics. Initial bleeding hemostasis (OTSC-a, 90.9%; OTSC-t, 87.9%; P = .82) and 72-hour mortality (OTSC-a, 4.5%; OTSC-t, 6.0%; P > .99) were not significantly different, but the OTSC-t group revealed a clearly higher rate of recurrent bleeding (34.9% vs 7.6%, P < .001) and necessity of red blood cell transfusions (5.1 ± 3.4 vs 2.5 ± 2.4 concentrates, P < .001).

CONCLUSIONS

For OTSC use, the OTSC-a should be the preferred option for duodenal ulcer bleeding.

Gastroduodenal Perforation in Cancer Patients: Association with Chemotherapy and Prognosis

Background: Gastroduodenal perforation stands out as one of the complications in cancer patients. Despite its high mortality, its characteristics are still poorly described. This study aimed to evaluate the characteristics and outcomes of cancer patients who had gastroduodenal perforation, and the influence of chemotherapy (CMT) in these cases. Method: A retrospective analysis of patients who underwent emergency surgery with an intraoperative finding of gastroduodenal perforation. Patients who performed CMT within 60 days before perforation were considered as the CMT group. Results: Among 45 patients included, 16 (35.5%) were classified as the CMT group and the remaining 29 (64.5%) patients as the non-CMT group. There was no difference between the groups regarding sex, age, BMI, comorbidity, and laboratory exams. ECOG 2-3 was significantly more frequent in the CMT group (68.8% vs. 34.5% p = 0.027). Major postoperative complications were similar between both groups (75% vs. 58.6%, p = 0.272). The sepsis of abdominal focus was the main postoperative complication. The 30-day mortality was 55.6%, with no difference between non-CMT and CMT groups (62.5% vs. 51.7%, respectively; p = 0.486). A multivariate analysis of risk factors showed that only an age of ≥65 years was related to 30-day mortality. Conclusions: Patients with gastroduodenal perforation and oncologic treatment present high mortality, regardless of receiving recent CMT.

Hepatic arterial haemorrhage caused by duodenal ulcer

A man in his late 60s with prior Hartman's procedure underwent colostomy takedown and complex ventral hernia repair. He subsequently developed gastrointestinal (GI) bleeding from a duodenal bulb ulcer. Despite five endoscopic procedures aimed at achieving haemostasis, including placement of an over-the-scope clip, and four endovascular embolisations (inferior and superior pancreaticoduodenal, right gastroepiploic and gastroduodenal arteries), the patient continued to experience episodic, haemodynamically significant bleeding. He eventually required emergency exploratory laparotomy, where the proper hepatic artery was identified as the source (a previously unreported phenomenon). He underwent antrectomy and proper hepatic artery ligation. This case highlights the need to interrogate all portions of the hepatic vasculature in the treatment of refractory GI bleeding.

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.

Recurrent Bleeding From a Duodenal Ulcer Halted by Laparoscopic Oversewing Under Endoscopic Guidance

Peptic ulcers are the most common causes of upper gastrointestinal bleeding. Although most peptic ulcer bleeding can be controlled by medical and endoscopic treatment, a small number of patients with recurrent bleeding eventually require surgical treatment. In recent years, laparoscopy, a minimally invasive surgical method, has gained popularity and acceptance. We, herein, report a case of recurrent duodenal ulcer bleeding. Laparoscopic oversewing of the bleeding ulcer under endoscopic guidance resulted in satisfactory recovery. We suggest that for recurrent bleeding from peptic ulcers, laparoscopic oversewing under endoscopic guidance should be recommended as a possible early option to halt the bleeding. Key Words: Upper gastrointestinal bleeding, Peptic ulcer, Laparoscopy, Treatment.

[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.

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.

; RESULTS OF RESECTION METHODS OF TREATMENT IN PATIENTS WITH GIANT PYLORODUODENAL ULCERS COMPLICATED BY PERFORATION AND BLEEDING

We studied the immediate and long-term results of various methods of gastric resection in 35 patients operated at the S.S. Yudin State Medical Center in Moscow from 2000 to 2019. 20 (57.1%) patients were operated on for perforation, and 15 (42.6%) patients underwent surgery for ulcerative bleeding. There were 27 (77.2%) males and 8 (22.8%) females. The average age of patients was 48.3±2.3 years. The diagnosis of peptic ulcer disease was previously made in 24 (68.6%) patients, the duration of the disease was 7.7±2.7 years. Of the 35 patients, 29 (82.8%) underwent standard gastric resection without vagotomy with Billroth-II anastomosis in various modifications and 6 (17.2%) underwent pylorobulbar resection with Billroth-I anastomosis with bilateral stem vagotomy. According to the analysis of the results of surgical interventions, gastric resection was accompanied by a significant number of early postoperative complications observed in 18 (51.4% of patients): associated with the nature of the operation, 10 and 5 patients had complications from the cardiovascular and respiratory systems. The most frequent complication due to the nature of surgery was a clinically significant violation of the evacuation function of the stomach stump, which developed in 8 of 35 (22.8%) patients. In 4 patients after pylorobulbar resection, the violation of the evacuation function of the stump was due to its parasympathetic denervation. The remaining 4 patients after standard resection of gastric stasis stump occurred due to maintenance of anastomositis of gastrojejunal anastomosis. Post-vagotomic diarrhea: observed in 3 of 6 patients: 1 patient of moderate severity, and 2 patients-mild. Failure of sutures was observed in 2 out of 35 (5.7%) patients after standard gastric resection: one after resection of Hofmeister Finsterer and the other after resection for PY. Complications from the cardiovascular system were observed in 5 (14.3%) patients. After surgery, 5 (22.7%) patients died: 4 after resection of 2/3 of the stomach and 1 patient after pyloroduodenal resection with stem vagotomy. All the deceased were operated on urgently: 2 patients for perforation of giant ulcers and 3 patients for continuing profuse bleeding. The causes of death of patients operated on for bleeding were: myocardial infarction in 1 patient, pulmonary embolism in 2 patients. Another 2 patients with failure of duodenal stump sutures, operated on for perforation of giant ulcers, died from increasing cardiovascular insufficiency. The analysis of long-term results of surgical interventions showed a steady decrease in the number of post gastric resection and post-vagotomic disorders, as well as the absence of ulcer recurrence. It should be noted that the phenomena of dumping syndrome observed in patients after standard gastric resection were not severe and were corrected by a lax diet. After piloroduodenal resection with anastomosis by Billroth-I and stem vagotomy, manifestations of gastrostasis and diarrhea were stopped in the remote postoperative period. When assessing the quality of life, there were no unsatisfactory results, all previously operated patients led their usual lifestyle, maintained their working capacity, and did not require re-hospitalization.

Gastroduodenal Surgery in Cirrhotic Patients - Case Series and Literature Review

Specific risk factors for gastroduodenal surgery in cirrhotic patients have been identified, which dictates for a more personalized management. The retrospective study was conducted between 2012-2019 on twelve patients (7 cases of duodenal ulcer, 2 cases of gastric ulcer and 3 patients with gastric cancer). We took into account a number of possible factors involved in the unfavorable evolution of patients, based on data published in the literature so far. In order to follow the involvement of each factor we compared two groups of patients, one with unfavorable evolutions, exitus and another with favorable evolutions. Emergency surgery, the presence of ascites at the time of intervention, a higher than 30 MELD score, alcoholic cirrhosis, liver encephalopathy and liver failure are common factors that are found in a high percentage (between 75% and 100%) in patients who have had an unfavorable evolution, exitus. The same risk factors are found in much lower percentages in patients who have evolved favorably postoperatively, most between 12.5% and 25%. We analyzed preoperative aspects, surgical approach, complications and risk factors for these patients, compared them with the results of our study and identified future therapeutic possibilities. For CHILD B or C patients, the indication for surgery should be discussed in advance with a multidisciplinary team. Endoscopic submucosal dissection or discontinuation of D2 dissection should be considered in these patients.

Gastroduodenal perforation in the pediatric population: a retrospective analysis of 20 cases

OBJECTIVE

The aim of this study was to investigate the pathogenesis, symptoms and individualized surgical management in pediatrics with gastroduodenal perforation (GDP).

METHODS

Patients diagnosed with GDP from January 2013 to December 2016 in our hospital were collected and divided into gastric perforation (GP) group and duodenal perforation (DP) group. Demographics, clinical events, etiological factors, symptoms, the time from symptom onset to operation, intraoperative findings and surgical procedures were analyzed. Follow-ups including ulcer, perforations occurrence, and digestive symptoms were carried out by out-patient review or telephones.

RESULTS

A total of 20 patients aged from 3 months to 14 years were enrolled in this study. The average age, main clinical presentations, size of perforations and operating time between two groups had no difference. The male to female ratio in DP group was higher than GP (P < 0.05). The high risk factor for DP was the use of dexamethasone, and for GP was HP infection. The most common site of perforation in DP group was duodenal bulb, and in GP group was pylorus area. Simple suture is the main management for both DP and GP, but distal gastrectomy combined with gastrojejunal Roux-en-Y anastomosis may be an alternative procedure for large perforation with diameter > 2 cm. The length of hospital days in GP group is shorter than DP group (P < 0.05). For follow-up, no patients had digestive symptoms.

CONCLUSIONS

The general condition had no difference between GP and DP patients. But the risk factors and surgical repair differ depending on the patient's fundamental illness and the complexity of the perforation.

[Current state of elective surgery for peptic ulcer]

AIM

To analyze the current state of elective surgery for peptic ulcer and to assess its significance for improving the results of treatment of this disease.

MATERIAL AND METHODS

The analysis included elective procedures for peptic ulcer performed in the surgical department of Tula Regional Clinical Hospital in the period from 2011 to 2015. These data were compared with those for the period 1996-2000 in order to objectively identify current changes in surgery for peptic ulcer. The interval between both periods was 10 years. The main group consisted of 47 patients with peptic ulcer who underwent surgery in 2011-2015. The control group included 254 patients who underwent similar procedures in 1996-2000.

RESULTS

Annual number of elective procedures for peptic ulcer decreased 5 times. There was advanced mean age in the main group, 29.8% of patients in the main group were older than 60 years, in the control group - 23%. Male/female ratio in the main group was 1:1, in the control group - 5:1. Prolonged ulcer history was observed in 10.6% of patients of the main group and 3.2% - in the control group. At the end of the last century, the greatest number of scheduled operations was performed for duodenal ulcer, now - for stomach ulcer. There was increased incidence of surgery for post-resection gastric syndrome (17 and 4.8% in both groups, respectively). We noted similar indications for elective surgical treatment of peptic ulcer in both groups. However, the negative feature of current period is significant augmentation of patients with decompensated pyloroduodenal stenosis. The structure of elective operations in 2011-2015 was characterized by significant proportion of decompensated complications of peptic ulcer as a result of prolonged medication. Prolonged postoperative hospital-stay and increased postoperative mortality were noted in the main group.

CONCLUSION

Reduced number of elective procedures for peptic ulcer is associated with changed structure of patients undergoing surgery. Unreasonable prolonged medication aggravates patient state and adversely affects the results of surgical treatment. The current state of elective surgery for peptic ulcer does not correspond to the objective to improve the results of treatment of this disease.

Laparoscopy in Acute Care Surgery: Repair of Perforated Duodenal Ulcer

INTRODUCTION

The use of laparoscopic management as a first choice for the treatment of duodenal perforation is gaining ground but is not routine in many centers. In this report, we aim to report our experience with laparoscopy as the first approach for the repair of duodenal perforation.

MATERIALS AND METHODS

This is a retrospective review of patients during our initial experience with the use of laparoscopy for the treatment of duodenal perforation between 2009 and 2013.

RESULTS

A total of 100 patients underwent management of duodenal perforation. Laparoscopy was attempted initially in 76 patients (76%) and completed in 64 patients (64%). The length of hospital stay was shorter in the laparoscopic group (mean 2.6) than in the open group (mean 3.1) (p = 0.008). Complications developed in 14 patients (20%). There was a tendency towards fewer admissions to intensive care, less acute kidney injuries, and less acute respiratory distress syndrome in the laparoscopic group. In patients who underwent laparoscopic surgery, the chances of uneventful recovery were 4.3 times higher than in those patients who underwent open surgery (95% CI 1.3-13.5, p = 0.014).

CONCLUSIONS

Laparoscopy in the treatment of perforated duodenal ulcer is safe and can be utilized as a routine approach for the treatment of this pathology.

Gastroduodenal Surgery: A Persistent and Continuing Challenge

The number of patients being treated surgically for gastroduodenal disease has decreased over the past five decades as a result of focus on medical treatment. However, perforated and bleeding peptic ulcer disease (PUD) continues to represent a significant percentage of patients who require emergency surgery. The aim of this study was to characterize these critically ill surgical patients treated for gastroduodenal disease in our hospital. A retrospective, single-center, consecutive cohort study of all patients identified from the hospital National Surgical Quality Improvement Program database who were admitted to our institution requiring emergent surgical intervention over the past two years was conducted. Of 423 patients, 33 (7.8%) had operative procedures for complications of PUD, of which 19 patients (57.6%) had perforation; nine patients (27.3%) had hemorrhage; one patient (3.0%) had both perforation and hemorrhage; two patients (6.1%) had distal gastrectomies for ulcers refractory to medical management alone, and two patients (6.1%) had gastrectomies for malignant gastric neoplasms. There is a significant population of patients who present with life-threatening complications of PUD, despite the decline in PUD worldwide. These patients are critically ill and require careful and diligent management for good outcomes.

Management of perforated duodenal peptic ulcer treated by suture

BACKGROUND

Laparoscopic surgery has become the gold standard for many procedures owing to its advantages such as a shorter post-operative stay, a faster recovery and less postoperative pain. However, choosing laparoscopic approach in an emergency situationsuch as in the management of a perforated duodenal peptic ulcer is still debated because of the absence of significant benefits. This study aimed to assess the management of perforated duodenal peptic ulcer treated by suture.

METHODS

It's a retrospective study enrolling 81 patients operated on for duodenal perforated peptic ulcer between June 1st, 2012 and December 31st, 2016 who underwent surgery in the surgical department B of Charles Nicolle's Hospital.

RESULTS

Our retrospective study showed that laparoscopic approach had shorter post-operative duration (3 [1-5] versus 4 [1-16] days, respectively, p< 0.001), shorter mortality rate (3% versus 19%, p=0.032) and more uneventful post-operative course (97% versus 74%, p=0.004) comparing to the open approach. Patients who were not admitted in the intensive care unit during the first 48 hours had 9.901 more chance to be operated by laparoscopic approach. Patients who were operated on by a senior had 3.240 times more chance to be operated by laparoscopic approach. There was no predictive variable for conversion. Mortality rate was 11%. Age was the only predictive independent factor of mortality with a cut-off point of 47 years.

CONCLUSIONS

Laparoscopic approach is routinely practised in the perforated duodenal ulcer. In our study, we showed that laparoscopic approach had less post-operative complications, a lower rate of mortality and a shorter post-operative duration comparing to the open approach. The main limitation of our study was non-randomization and lack of laparoscopic expertise. The decision for either open or laparoscopic approach was then dependent on senior surgeon's availability.

An unexpected complication of a heterotopic ossified abdominal scar

AIM

Presentation and discussion of a case of heterotopic ossification of a vertical abdominal surgical scar.

PERSONAL OBSERVATION

A recent trauma in an 70 year old patient, followed by a sudden internal hemorrhage because of a penetration in abdomen of a bone stump, originated from a fracture of a not known heterotopic ossification of an old median abdominal scar, of a laparotomy of many years earlier for perforated duodenal ulcer.

RESULTS

An emergency surgery was mandatory DISCUSSION: Pathogenesis of heterotopic ossification, as rare metaplastic phenomenon outside of the normal bone tissue, still unknown and speculative.

CONCLUSION

Despite the rarity the complications of heterotopic bone formation can also be very dramatic following a trauma that transforms the new bone into traumatic agent, as in the present observation.

KEY WORDS

Heterotopic ossification, Ossified abdominal scar.

Laparoscopy for perforated duodenal ulcer: A morbidity score based on a cohort study of 384 patients

BACKGROUND

The Laparoscopic treatment of perforated ulcer is accompanied by a lesser morbidity and mortality compared with treatment by laparotomy. However, the morbidity of the laparoscopic approach is not nil (4%). It is influenced by pre and intraoperative factors. The aim of our work is to establish a morbidity score in patients undergoing laparoscopic surgery for acute peritonitis with perforated duodenal ulcer.

METHODS

This is a retrospective study conducted in a General Surgery Department. We included 384 cases of perforated duodenal ulcer operated laparoscopically over a fourteen-year period ranging from January 2000 to December 2014. We conducted a multivariate logistical regression analysis by step-by-step-descending method. From these independent factors we established a score using the ROC curves. The threshold with the best sensitivity and specificity for predicting morbidity was investigated. In all statistical tests, the significance level was set at 0.05.

RESULTS

The overall morbidity rate of our patients was 3.38% (13 patients). Multivariate analysis has identified five independent morbidity risk factors: temperature higher than 37.6° C, renal failure, age> 45 years, a number of stitches of two or higher and operating time to 75 minutes or longer. Our morbidity score took into account these 5 factors by integrating the intrinsic value of each factor. The threshold of the score having the best torque sensitivity specificity to predict morbidity was 10.

CONCLUSION

A morbidity score for perforated duodenal ulcer surgery performed by laparoscopy may be useful to organize the post-operativecare of these patients usually young and active. A lower score than the threshold predictive of morbidity could allow a rapid rehabilitation of these patients and a one day hospitalization management.

[Fast track rehabilitation in perforated duodenal ulcer]

AIM

To analyze the outcomes of fast track rehabilitation program in patients with perforated duodenal ulcer (PDU).

MATERIAL AND METHODS

For the period 2013-2016 at the Department of Surgery and Endoscopy 206 PDU patients have been treated. Inclusion criterion for the main group (n=77) was duodenal ulcers, their dimension up to 1 cm, laparoscopic suture of perforated ulcer, fast track rehabilitation program implementation. The control group consisted of 129 patients who underwent open suturing of perforated ulcer followed by conventional treatment in postoperative period.

RESULTS

In the main group (n=77) laparoscopic suturing of ulcerative defect with the use of Fast Track program was performed. Postoperative complication i.e. sutures failure was observed in 1 (1.3%) case. There were no lethal outcomes in the main group. Mean length of hospital-stay was 4.8 days. In 129 patients of the control group open suturing of the perforated ulcer and conventional postoperative therapy were applied. Postoperative surgical complications were absent in the control group; mortality rate was 2.3%. Mean length of postoperative hospital-stay was 8.1 days.

CONCLUSION

Laparoscopic treatment of perforated ulcers facilitates application of fast track rehabilitation program in emergency patients. Fast track rehabilitation protocol after laparoscopic suturing of the perforated ulcer creates conditions for early discharge and is followed by good clinical and economic effects. Recurrent peptic ulcers are noted if antiulcer therapy is absent.

Clinical characteristics of peptic ulcer perforation in Korea

AIM

To elucidate the epidemiological characteristics and associated risk factors of perforated peptic ulcer (PPU).

METHODS

We retrospectively reviewed medical records of patients who were diagnosed with benign PPU from 2010 through 2015 at 6 Hallym university-affiliated hospitals.

RESULTS

A total of 396 patients were identified with postoperative complication rate of 9.1% and mortality rate of 0.8%. Among 174 (43.9%) patients who were examined for Helicobacter pylori (H. pylori) infection, 78 (44.8%) patients were positive for H. pylori infection, 21 (12.1%) were on non-steroidal anti-inflammatory drugs (NSAIDs) therapy, and 80 (46%) patients were neither infected of H. pylori nor treated by any kinds of NSAIDs. Multivariate analysis indicated that older age (OR = 1.09, 95%CI: 1.04-1.16) and comorbidity (OR = 4.11, 95%CI: 1.03-16.48) were risk factors for NSAID-associated PPU compared with non-H. pylori, non-NSAID associated PPU and older age (OR = 1.04, 95%CI: 1.02-1.07) and alcohol consumption (OR = 2.08, 95%CI: 1.05-4.13) were risk factors for non-H. pylori, non-NSAID associated PPU compared with solely H. pylori positive PPU.

CONCLUSION

Elderly patients with comorbidities are associated with NSAIDs-associated PPU. Non-H. pylori, non-NSAID peptic ulcer is important etiology of PPU and alcohol consumption is associated risk factor.

Upper gastrointestinal haemorrhage in severe dengue: To scope or not to scope?

Upper gastrointestinal haemorrhage (UGIH) in severe dengue represents a clinical dilemma in term of management. The recommended treatment in dengue with UGIH involves blood product transfusion support and proton pump inhibitor (PPI) infusion. Despite being the mainstay of treatment in non-dengue UGIH, the role of endoscopic haemostatic intervention in severe dengue remains controversial. In the present report, we present a case of severe dengue complicated with upper gastrointestinal haemorrhage successfully underwent early therapeutic endoscopic intervention in a district hospital.

A case of gastrojejunocolic fistula with steatohepatitis

A man in his 30s, who had undergone retrocolic Billroth II reconstruction for perforated duodenal ulcer, presented with watery diarrhea for 2 years and suspected fatty liver. He was referred to our hospital for management of chronic diarrhea, weight loss, hepatopathy and hypoalbuminemia. Initial upper and lower gastrointestinal endoscopies were negative. Since a small bowel lesion was suspected, peroral single-balloon enteroscopy was performed, which identified feces-like residue near the Billroth II anastomotic site and a connection to the colon separate from the afferent and efferent loops. Transanal single-balloon enteroscopy identified a fistula between the gastrojejunal anastomosis and transverse colon, with the scope reaching the stomach transanally. Barium enema confirmed flow of contrast medium from the transverse colon through the fistula to the anastomotic site, allowing the diagnosis of gastrojejunocolic fistula. Liver biopsy showed relatively severe steatohepatitis (Brunt's classification: stage 2-3, grade 3). Resection of the anastomotic site and partial transverse colectomy were performed to remove the fistula, followed by Roux-en-Y reconstruction. Postoperatively, watery diarrhea resolved and the stools became normal. Hepatopathy and hypoproteinemia improved. One year later, liver biopsy showed marked improvement of steatosis. This case demonstrated marked improvement of both diarrhea/nutritional status and steatohepatitis after treatment of gastrojejunocolic fistula, suggesting that the fistula caused non-alcoholic steatohepatitis.

[Not Available]

Detailed statistic alanalysis of the treatment results in patients, who have had suffered gastroduodenal ulcer hemorrhage, in The Gastro—Intestinal Hemorrhage Centre, was performed. Application of exteriorization procedure, using original method of double sticking and out sticking of the needle bilaterally from ulcerative defect, for duodenal ulcer, complicated by hemorrhage, have had guaranteed mechanical squeezing of the periulcer zone vessels and effective removal of the ulcer out side the gut lumen. This have had promoted improvement of the patients' treatment results.

Doppler endoscopic probe as a guide to risk stratification and definitive hemostasis of peptic ulcer bleeding

BACKGROUND AND AIMS

For more than 4 decades endoscopists have relied on ulcer stigmata for risk stratification and as a guide to hemostasis. None used arterial blood flow underneath stigmata to predict outcomes. For patients with severe peptic ulcer bleeding (PUB), we used a Doppler endoscopic probe (DEP) for (1) detection of blood flow underlying stigmata of recent hemorrhage (SRH), (2) quantitating rates of residual arterial blood flow under SRH after visually directed standard endoscopic treatment, and (3) comparing risks of rebleeding and actual 30-day rebleed rates for spurting arterial bleeding (Forrest [F] IA) and oozing bleeding (F IB).

METHODS

Prospective cohort study of 163 consecutive patients with severe PUB and different SRH.

RESULTS

All blood flow detected by the DEP was arterial. Detection rates were 87.4% in major SRH-spurting arterial bleeding (F IA), non-bleeding visible vessel (F IIA), clot (F IIB)-and were significantly lower at 42.3% (P < .0001) for an intermediate group of oozing bleeding (F IB) or flat spot (F IIC). For spurting bleeding (F IA) versus oozing (F IB), baseline DEP arterial flow was 100% versus 46.7%, residual blood flow detected after endoscopic hemostasis was 35.7% versus 0%, and 30-day rebleed rates were 28.6% versus 0% (all P < .05).

CONCLUSIONS

(1) For major SRH versus oozing or spot, the arterial blood flow detection rate by the DEP was significantly higher, indicating a higher rebleed risk. (2) Before and after endoscopic treatment, spurting (F IA) PUB had significantly higher rates of blood flow detection than oozing (F IB) PUB and a significantly higher 30-day rebleed rate. (3) The DEP is recommended as a new endoscopic guide with SRH to improve risk stratification and potentially definitive hemostasis for PUB.

[THE TREATMENT TACTICS IN GASTROINTESTINAL ULCER HEMORRHAGE]

Experience of the patients treatment, suffering gastrointestinal ulcer hemorrhage, in Municipal Centre, dealing with such cases, was summarized. There was established, that conduction of endoscopic monitoring is indicated in all patients, suffering gastrointestinal ulcer hemorrhage for early diagnosis of the hemorrhage recurrence signs and conduction of prophylactic measures. Introduction of local endoscopic hemostasis, еndoscopic monitoring in complex of conservative therapy have permitted to reduce the operative interventions conduction rate in 2,5 times.

[APPROACH TO ESTABLISHMENT OF INDICATIONS FOR PROGRAMMED SANATION OF ABDOMINAL CAVITY IN DIFFUSE PERITONITIS]

The results of treatment of 33 patients, suffering diffuse peritonitis, with postoperatively applied tactics of the programmed surgical sanation of abdominal cavity were analyzed. Indications for relaparotomy were established, based on the estimation scale for the enteral insufficiency severity. The patients death and the complications causes were analyzed, depending on terms and rates of relaparotomy conduction.

PERFORATED DUODENAL ULCER ASSOCIATED WITH SITUS INVERSUS AND DEXTROCARDIA

A 32 years old gentleman, presented in emergency department, with complaints of sudden onset of severe upper abdominal pain, associated with nausea and vomiting. He was a known case of acid peptic disease. His abdominal examination showed signs of peritonitis. X-ray chest showed pneumoperitoneum, with dextrocardia. Ultrasound showed situs inversus. Exploration confirmed the diagnosis of perforated ulcer and situs inversus. Grahm's patch repair of perforation was done. His postoperative recovery was smooth.

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.

[Difficulty in Preoperative Diagnosis of Residual Gastric Cancer after Distal Gastrectomy for Duodenal Ulcer]

A 67-year-old man underwent distal gastrectomy via the Billroth Ⅱ method (B-Ⅱ) for a duodenal ulcer. He presented with appetite loss and nausea in May 2014. Gastrointestinal endoscopy revealed wall thickness around gastrojejunostomy and the gastric mucosal fold. Biopsy and re-biopsy revealed a group 2 tumor. Laparotomy for diagnosis was performed because of stenosis and tumor progression. Intraoperative frozen section examination revealed adenocarcinoma in the lymph nodes of the jejunum. Residual gastrectomy with reconstruction using the Roux-en-Y method was performed for residual gastric cancer. Histopathological findings revealed pT4a, pN0, pM1 for the tumor in the lymph nodes of the jejunum, pStage Ⅳ. A distorted gastrojejunostomy site and the presence of anastomotic strictures are important for the rapid diagnosis of residual gastric cancer.

[IMPACT OF OPERATIVE INTERVENTION ON DYNAMICS OF THE IMMUNITY INDICES IN AN ACUTE GASTRODUODENAL HEMORRHAGE]

The results of surgical treatment of 39 patients, suffering an acute gastroduodenal ulcer hemorrhage, were analyzed. Gastric ulcer disease was diagnosed in 9 patients, duodenal ulcer disease--in 29, combined ulcer--in 1. A light degree blood loss was noted in 13 patients, while a middle degree--in 12, and severe--in 14. In accordance to J. Forrest classification in 6 patients an active bleeding was revealed (FIa, FIb), in 11--nonstable hemostasis (FIIa, FIIb, FIIc), and in 22--FIII. Preoperatively in patients on the third, seventh and fourteenth day the contents of CD3+, CD4+, CD8+, CD19, calculation of a CD4+/CD8+ ratio, the level of immunoglobulins (IgA, IgM, IgG) and circulating immune complexes were determined in peripheral blood. Phagocytic activity of neutrophils was estimated, using determination of phagocytic index and phagocytic number. In an acute gastroduodenal ulcer hemorrhage immunosuppression was noted, and severity of disorders in T- and B-chains of immunity have depended upon a blood loss severity. Conduction of a routine basic conservative therapy in postoperative period did not guarantee elimination of immunosuppression.

Successful treatment of life-threatening bleeding from a duodenal posterior bulb peptic ulcer by an over-the-scope-clip

Bleeding of peptic ulcer at the posterior duodenal bulb still is a particular endoscopic challenge with increased risk of treatment failure and worse outcome. In this article, we report successful treatment of an actively bleeding peptic ulcer located at the posterior duodenal wall, using an over-the-scope-clip in the case of a 54-year-old male patient with hemorrhagic shock. Incident primary hemostasis was achieved and no adverse events occurred during a follow-up of 60 d.

[PRINCIPLES OF POSTOPERATIVE DRUG THERAPY OF COMPLICATED DUODENAL ULCERS]

The article highlights the principles of individualized drug therapy of complicated duodenal ulcers in the postoperative period, based on the removal of the pathophysiological changes that occurred after different types of medical or surgical benefits.

A Duodenal Ulcer Caused by Pancreatic Ductal Hypertension with Chronic Pancreatitis

We herein describe the case of a 67-year-old woman with a duodenal ulcer thought to be caused by elevated pancreatic ductal pressure. The patient complained of continuous upper abdominal pain. Her medical history included idiopathic chronic pancreatitis. Endoscopy revealed a huge duodenal ulcer located on the inferior duodenal angle, which had not been seen on endoscopic retrograde pancreatography two months previously. A combination study using endoscopy and contrast imaging confirmed the relationship between the duodenal ulcer and the pancreatic branch duct. To our knowledge, this is the first case of duodenal ulcer thought to be caused by elevated pancreatic ductal pressure.

[CLINICAL, ENDOSCOPIC AND MORPHOLOGICAL FEATURES OF GASTROESOPHAGEAL REFLUX DISEASE IN PATIENTS WITH CERTAIN SURGICAL DISEASES OF THE UPPER GASTROINTESTINAL TRACT]

OBJECTIVE

To reveal the peculiarities of manifestations and treatment of gastroesophageal reflux disease (GERD) in patients with peptic ulcer disease of the stomach and duodenum, hiatal hernia (HH) and after stomach resection.

MATERIALS AND METHODS

387 patients with GERD, peptic ulcer disease of the stomach and duodenum (200 patients), after resection of the stomach Billroth II (150 patients), 37 patients with HH. Videoendoscopic equipment company OLYMPUS (Japan) was used. Biopsies of the mucous membranes of the pylorus, body, angle of the stomach and esophagus were studied to identify preneoplastic changes. HP was determined histologically, cytologically, urease tests.

RESULTS

The patients with GERD and peptic ulcer disease of the stomach and duodenum were complained on the heartburn, the patients after resection of the stomach--on feeling bitterness in the mouth, with HH--on the pain behind the breastbone. More severe degree of GERD (C and D) was endoscopic feature in patients with HH and A degree or endoscopic negative form--after resection of the stomach. Preneoplastic changes of the esophageal mucosa with columnar epithelium were found in cases of less severe degrees of inflammation. The degree of esophagitis, presence of preneoplastic changes were determined depending on the presence of Helicobacter pylori. Antireflux surgery was performed under strict indications.

CONCLUSION

Clinical features, endoscopic, morphological manifestations of GERD in patients with pectic ulcer disease of the stomach and duodenum, with resection of the stomach and patients with HH were determined. This is dictated the individual differentiated approach to the choice of the treatment.