DOI: http://dx.doi.org/10.18203/2349-2902.isj20194418

Surgical outcome of management of perforated peptic ulcer: retrospective analysis of 148 cases

Salamat Khan, O. P. Gupta

Abstract


Background: Perforated peptic ulcer (PPU) is a common life threatening surgical emergency. Discovery of H. pylori (1985) changed the concept of the management of peptic ulcer. Now-a-days reduction in gastric acid production with proton pump inhibitors along with eradication of H. pylori is recommended.

Methods: Clinically suspected cases of PPU were confirmed by radiological and laboratory investigation. These patients were subjected to exploratory laparotomy with Graham’s omental patch repair after adequate fluid resuscitation with optimal hemodynamic status with or without peritoneal drainage, except in too sick patients. Postoperatively; these patients kept in SICU and closely monitored. Data were collected, tabulated and analyzed.

Results: Out 150 cases enrolled, 2 cases died before exploratory laparotomy and closure of operation. So only 148 took part in the study. Male patients were predominant than female in a ratio of 148:2. Age ranges from 20 to >60 years. Majority of the patients belongs to the age group 30-40 years of age. The morbidity and mortality rates were 20% and 2.7% respectively.

Conclusions: Adequate fluid resuscitation with optimal hemodynamic status and optimal kidney function is the key to decrease morbidity and mortality rates. Simple closure with omental patch followed by H. pylori eradication is effective with excellent outcome in most of survivor despite of late presentation. Old concept of prophylactic peritoneal drainage and “no sunset no sun rise” concept of operation should be discouraged as it is not beneficial. Definitive surgery for ulcer recurrence is no more done except in special situation.


Keywords


Perforated peptic ulcer, Peritonitis, Graham’s omental patch

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References


Testini M, Portincasa P, Piccinni G, Lissidini G, Pellegni F, Greco L. Significant factors associated with fatal outcome in emergency open surgery for perforated peptic ulcer. WJ Gastroenterol. 2003;9:2338-40.

Feldman M, Friedman L, Brandt L. Peptic ulcer and its complications. In: Scharschmidt BF, Sleinger MH. Sleisinger and Fordtran’s gastrointestinal and liver disease: pathophysiology, diagnosis, management. 6th ed. Philadelphia: W. B. Saunders; 1998: 620-678.

Rajesh V, Sarathchandra S, Smile SR. Risk factors predicting operative mortality in perforated peptic ulcer disease. Trop Gastroenterol. 2003;24:148-50.

Hermansson M, Holstein CS, Ziling T. Surgical approach and prognostic factors after peptic ulcer perforation. Eur J Surg. 1999;165:556-72.

Boey J, Choi KY, Alagarantnam TT, Poon A. Risk stratification in perforated duodenal ulcer: a prospective validation of predictive factors. Ann Surg. 1986;205:22-6.

Elnagib E, Mahdi SE, Mohamed E, Ahmed ME. Perforated peptic ulcer in Khartoum. Khartoum Med J. 2008;1(2);62-4.

Gutierrez L, Pena C, Merquez R, Fakih F, Adame E, Medina J. Simple closure or vagotomy and pyloroplasty for the treatment of a perforated duodenal ulcer comparison of results. Dig Surg. 2000;17:225.

Baron JH. Peptic ulcer. Mount Sinai J Med. 2000;67:58-62.

Baron JH, Snnenberg A. Publication on peptic ulcer in Britain, France, Germany and The US. Eur J Gastroenterol Hepatol. 2002;14:711-5.

Schein M. Perforated peptic ulcer. In: Klipfel A, Fahoum BH, Gecelter G, Goreck P, Hirshberg A, Nystrom PO, et al, eds. Schein’s common sense emergency abdominal surgery. Part III. Berlin: Springer-Verlag Berlin Heidelberg GmbH; 2005: 143-150.

Rayner HH. Treatment of perforated peptic ulcer. Lancet. 1930;2:107-8.

Sangter AH. Perforated peptic ulcer: an analysis of 100 consecutive cases. Lancet. 1939;23:1311-3.

Birk PM. Perforated peptic ulcer treated without operation. Lancet. 1947;4:467-8.

Lu WY, Leow CK. History of perforated duodenal and gastric ulcer. World J Surg. 1997;21:890-6.

Lagoo S, McMahon RL, Kakihra M, Pappas TN, Eubanks S. The sixth decision regarding perforated duodenal ulcer. JSLS. 2002;6:359-68.

Fujii Y, Asato M, Taniguchi N, Shigeta k, Omoto K, Itoh K, et al. Sonographic diagnosis and successful non-operative management of sealed perforated duodenal ulcer. J Clin Ultrasound. 2003:31:55-8.

Mishra SP, Prusti PN, Mishra BP. Surgical management of acute perforated duodenal ulcer. IJS. 1982;705-10.

Rains AJH, Capper WM, Knights, Cleland WP, Freeman MAR. Baily and Love’s short practice of surgery. 15th ed. London: HK Lewis and company; 1971: 770.

Trolley JA. Definitive surgical therapy for perforated peptic ulcer. A review of 52 consecutive cases. Am J Surg. 1967;113:327-34.

DeBaky ME. Acute perforated gastroduodenal ulcer: a statistical analysis and review of literature. Surg. 1994;8:852-84.

Zittel TT, Jehle EC, Becker HD. Surgical management of peptic ulcer disease today: indication, technique and outcome. Lagenbecks Arch Surg. 2008;385:84-96.

Dovonan AJ, Berne TV, Dunovon JA. Perforated duodenal ulcer: an alternative therapeutic plan. Arch Surg. 1998;133:1166-71.

Schwesinger WH, Page CP, Srinek KR, Gaskill H, Melnick G, Strodel WE. Operation for peptic ulcer disease: paradigm lost. J Gastrointest Surg. 2001;5:438-43.

Bucher P, Oulhaci W, Morel P, Ris F, Huber O. Results of conservative treatment for perforated gastroduodenal ulcer in patients not eligible for surgical repair. Swiss Med Weekly. 2007;137: 337-40.

Crofts TJ, Park KG, Steele RJ, Chung SS, Li AK. A randomized trial of non-operative treatment for perforated peptic ulcer. N Engl J Med. 1989; 320:970-3.

Tuscott B, Withycombe JFR. Perforated peptic ulcer. An assessment of value of non-operative treatment. Lancet. 1950;13:894-6.

Schein M. To drain or not to drain? The role of drainage in contaminated and infected abdomen: an international and personal perspective. World J Surg. 2008;32:312-21.

Khan S, Rai P, Misra G. Is prophylactic drainage of peritoneal cavity after gut surgery necessary? A non- randomized comparative study from a teaching hospital. ICDR. 2015;9(10):PC01-3.

Cellan-Jones CJ. A rapid method of treatment of perforated duodenal ulcer: a randomized controlled trial. Ann Surg. 2002;235:313-9.

Graham RR. The treatment of perforated duodenal ulcer. Surg Gynecol Obstet. 1937:235-8.

Lunevicius R, Morkevicius M, management strategies, early results, benefits and risk factors of laparoscopic repair of perforated peptic ulcer. World J Surg. 2005;29:1299-310.

Whiteside OJ, Tytherleigh MG, Thrush S, Farouk R, Gilland R B. Intraoperative peritoneal lavage-who does it and why? Ann R Coll Surg Engl. 2005;87:255-8.

Pai D, Sharma A, Kanungo R, Jagdish S, Gupta A. Role of abdominal drain in perforated duodenal ulcer patients: a prospective controlled study. Aust NZ J Surg. 1999;69:210-3.

Jordan PH, Thornby J. Perforated pylorodudenal ulcer: long term results with omental patch closure and parietal cell vagotomy. Ann Surg. 1995;221:479-88.

Herbison SP, Dempsy DT. Peptic ulcer disease. Curr Probl Surg. 2005;42:346-454.

Nelson R, Edwards S, Tse B. Prophylactic nasogastric decompress after abdominal surgery. Cochrane Database Syst Rev (online). 2007;CD004929.

Simmen HP, Bataglia H, Kossmann T. Blaser J. Effect of pH in peritoneal fluid on outcome of aminoglycoside treatment in intra-abdominal infections. World J Surg. 1993;17:393-7.

Khan S, Gupta DK, Khan DN. Comparative study of three antimicrobial drug protocol (ceftriaxone, gentamicin or amikacin and metronidazole versus two antimicrobial drug protocol (ceftriaxone and metronidazole) in cases of intra-abdominal sepsis. KUMJ. 2005;3(9):55-63.

Lam PW, Lam MC, Hui EK, Sun YW, Mok FP. laparoscopic repair of perforated duodenal ulcer, the three stitch Graham’s patch technique. Surg Endosc. 2005;19:1627-30.

Shah PH, Panchal HA. Acute perforation: clinical profile and our experience with operative outcome. Int Surg J. 2016;3(4):2227-32.