Management of acute duodenal peptic perforations.

In this issue of the Southern Medical Journal, Jani et al (1) present a prospective randomized study of 100 patients with acute duodenal perforations. The patients were randomized to either Graham omentopexy or omental plugging technique. The primary endpoint of the study was postoperative mortality. The secondary endpoints were postoperative suture line leak, postoperative hemorrhage, and evidence of gastric outlet obstruction by endoscopy and upper GI barium study. All duodenal perforations were at least 2 cm in size. Nearly half the patients had a history suggestive of chronic ulcer symptoms for more than 3 months' duration. The authors did not indicate the number of patients who presented in shock. The mean age in both groups was less than 40 years old with a male predominance. Gastrograffin upper GI study detected a suture line leak in six patients treated with a Graham patch (12%), but none in the omental plug group. This difference was found to be statistically significant. The postoperative mortality rate was 16% (8 patients) in the omentopexy group and 8% (4 patients) in the omental plug treatment arm. All deaths in the study were attributed to sepsis. Early gastric outlet obstruction was significantly greater in the omentopexy group, but at five years, this difference was insignificant. The authors concluded that the technique of omental plugging had a significantly lower leak rate and was less likely to obstruct the pylorus compared with the Graham technique.

The introduction of new acid-reducing drug therapies, and the recognition of the potential pathogenic role of Helicobacter pylori has ushered in a new era in the management of peptic ulcer disease, culminating in a sharp decline in elective peptic ulcer surgery. However, this change has been buffered by a corresponding increase in the incidence of emergency peptic ulcer surgery for the complications of peptic ulcer, mainly attributed to the increasing use of nonsteroidal anti-inflammatory drugs (NSAIDs).

Several investigators now believe the indications for surgery in patients with perforated duodenal ulcers have changed. (2) It is widely recognized that perforated ulcers frequently seal spontaneously by the adherence of omentum or adjacent organs to the perforation. When a water-soluble contrast study confirms that the perforation has sealed, it may be reasonable to pursue nonoperative management. The current guidelines for nonoperative management include fluid resuscitation, placement of nasogastric tube, use of broad-spectrum antibiotics, proton pump inhibition, antibiotics to eradicate H pylori, close monitoring of the hemodynamic status, and serial abdominal examinations. This approach has been shown to be safe and effective in a randomized controlled trial. (3) This policy tends to require a longer hospital stay than for surgically treated patients and more often fails in patients over the age of 70 years old. Nonetheless nonsurgical treatment is successful at least 80% of the time. (4) For those who fail nonoperative therapy, the treatment of choice is omental patch closure of the duodenal perforation, which can be performed via a laparotomy (open) incision or laparoscopically. There are several potential advantages to the minimally invasive approach. These include decreased postoperative analgesic requirements, lower incidence of wound complications such as infection and incisional hernia formation, quicker resumption of oral intake, shorter hospital stay, and a quicker return to work. One disadvantage of laparoscopic ulcer closure is the longer operating time which can be rectified by employing the sutureless technique, which consists of using a gelatin plug and application of fibrin glue to close the perforation. The laparoscopic closure technique is contraindicated in the presence of shock and symptoms of perforation for greater than 24 hours. (5)

The age of the patient, clinical presentation, use of NSAIDs, and presence of H pylori, which has been found to infect at least 90% of patients with perforated duodenal ulcers, all play a major role in the management algorithm of patients with acute duodenal peptic ulcer perforation. (6) Patients younger than 50 years old who present with a perforated duodenal ulcer without shock and do not take NSAIDs are likely to have H pylori infection and are reasonable candidates for nonoperative treatment as outlined above, as well as H pylori eradication. Patients older than 50 years old in this group are good candidates for the minimally invasive procedure. For patients with chronic ulcer symptoms of more than 3 months' duration, who are negative for H pylori and are unable to discontinue NSAIDs, who acutely perforate within 24 hours, the recommendation is surgical closure of their duodenal perforation followed by definitive surgical treatment of their peptic ulcer diathesis. The traditional open approach of omental patch/plug is reserved for those patients presenting in shock.

References

1. Jani K, Saxena AK, Vaghasia R. Omental plugging for large sized duodenal peptic perforations: a prospective randomized study of 100 patients. South Med J 2006;99:467-471.

2. Jamieson GG. Current status of indications for surgery in peptic ulcer disease. World J Surg 2000;24:256-258.

3. Crofts TJ, Park KG, Steele RJ, et al. A randomized trial of nonoperative treatment for perforated peptic ulcer. N Engl J Med 1989;320:970-973.

4. Marshall C, Ramaswamy P, Bergin FC, et al. Evaluation of a protocol for the non-operative management of perforated peptic ulcer. Br J Surg 1999; 86:131-134.

5. Katkhouda N, Mavor E, Mason RJ, et al. Laparoscopic repair of perforated duodenal ulcers: outcome and efficacy in 30 consecutive patients. Arch Surg 1999;134:845-850.

6. Lickstein LH, Matthews JB. Elective surgical management of peptic ulcer disease. Problems in General Surgery 1997;14:37-53.

Begin somewhere; you cannot build a reputation on what you intend to do.
--Liz Smith

Carmine M. Volpe, MD, FACS 

From the Division of Surgical Oncology, Department of Surgery, Temple University School of Medicine, The Western Pennsylvania Hospital, Pittsburgh, PA.

Reprint requests to Carmine M. Volpe, MD, Department of Surgery, Suite 4600N, 4800 Friendship Avenue, Pittsburgh, PA. Email: [e-mail]

Accepted February 17, 2006.